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UNITED STATES OF AMERICA. 



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HERIA, C 



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OR, 



THE MEMBRANOUS DISEASES: 



THEIR 



NATURE, HISTORY, CAUSES, AND TREATMENT; 

WITH A REVIEW OF 

THE PREVAILING THEORIES AND PRACTICE OF 
THE MEDICAL PROFESSION ; 

ALSO, 
A DELINEATION OF THE NEW 

CHLORAL HYDRATE 
Method of Treating the Same; Its Superior Success, 

AND ITS TITLE TO BE CONSIDERED 

A SPECIFIC. 



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C. B. GALENTIN, M. 



Ail 17 

CLEVELAND, O. 

Printed at the Publishing House of the Evangelical Association, 




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Entered according to Act of Congress, in the year 1884, by 

G. B. GALENTIN, 
In the office of the Librarian of Congress, at Washington. 



All rights reserved. 



PRE FA C E. 



Whoever adds a new book to the long catalogue of medical 
works, should have something to say which has either not 
been well said before, or that is new. On the subjects- 
treated in this volume much has been well said and written 
by men in the profession, eminent as writers and teachers. 
In history, aetiology and pathology, it can be truthfully said r 
they have constructed an almost faultless edifice, wanting' 
only a therapeutic finish to complete the fabric. On this 
latter only has the writer anything very important or new to 
contribute. On the therapeutics of diphtheria so indefinite 
and diverse have been the opinions of the architects, that 
the laborious student is more dazed than edified, by being 
conducted into voluble labyrinths that end in the confusion 
of uncertainty and doubt. " Systematic feeding," and direc- 
tion to " treat the symptoms as they arise," is nearly the sum 
of what has been developed in the medical treatment of 
diphtheria. 

The writer has been led, or driven, into a new and hitherto' 
untried field of therapeutics in this destructive disease, and 
for several years, in the treatment of hundreds of cases, has 
demonstrated to his entire satisfaction the claims of Chloral 
Hydrate to specific efficacy in the membranous diseases, 
diphtheria, croup, &c. It is expected that this announce- 
ment will be received with reserve and a measure of incredul- 
ity, even by men of fair minds and culture ; by others pos- 
sibly with positive contradiction and opposition, and by 
another too numerous class 6f pompous, opinionated and 
bigoted men, or doctors, if you please, with derision. These 

in 



IT PREFACE. 

latter are the obstructionists of progress, ever ready to sneer 
at, and strive to detract from the influence of anj^ discovery 
in medicine so unfortunate as not to have been developed 
beneath their own hats. However it may be received hj the 
profession, it is confidently believed that it will be sustained 
'fry experience, and will stand, as have other truths, upon its 
own merits. 

Other practitioners of ripe age and large experience, both 
in this city, and elsewhere, at the suggestion of the writer, 
have tested the efficacy of chloral in a very large number of 
cases of diphtheria, and unhesitatingly affirm its efficacy, as 
superior to any other known treatment. 

Among these I mention with pleasure my esteemed and 
scholarly friend, Dr. A. G-. Hart, and my daughter and co- 
laborer in this work, to whom its merits, if an} T be ac- 
corded it, are largely due. Finally, to those whose lives 
and labors are honestly devoted to the true interests of 
the noble profession of medicine, and the welfare of human- 
ity, I wish to say, 

Gentlemen, the writer submits whatever is new and use- 
ful in this little volume to you, for your careful consideration 
and use ; in the pleasing hope of rendering both to you, 
and through you, to the world, a tittle of the good service 
we owe each other and humanity, with a humilitating sense 
of its many defects. 

c. b. a. 



CONTENTS, 



Introduction vn 

Diphtheria. 

Chapter I. Definition 1 

" II. Nomenclature 2 

III. History 2 

IV. Cause 14 

u V. Climatic and Atmospheric Influences ... 31 

" VI. Mode of Propagation 33 

" VII. Predisposing Causes 39 

" VIII. Period of Incubation 42 

" IX. Prophylaxis 44 

■" X. Symptoms 45 

" XI. Diagnosis , . 64 

" XII. Prognosis 66 

" XIII. Pathology 69 

«» XIV. General Treatment 77 

" XV. Therapeutic Treatment. 81 

«■ XVI. Local Treatment 84 

" XVII. Constitutional Treatment 92 

Chloral Treatment . Ill 

<* XVIII. Nasal Diphtheria 121 

" XIX. Laryngeal Diphtheria 123 

" XX. Treatment of Diphtheritic Paralysis .... 126 

» XXI. Medical Prophylaxis 127 

" XXII. Croup , 129 

" XXIII. Tracheotomy 151 

" XXIV. Plastic Bronchitis 156 

Foemul^: 163 

v 



INTRODUCTION. 



The treatment of different diseases by similar remedies, as 
advocated in the following pages, to thoughtful practitioners 
will appear neither strange nor unreasonable. Diseases 
differing widely in their essential characters, are not infre- 
quently related by symptoms or phenomena that are common 
to several. 

The entire system of the so-called " Rational treatment of 
disease," indeed, consists in the treatment of the symptoms as 
they arise, if we except only the few instances in which the 
treatment is specific. Pain in the chest for example, may be 
occasioned by a variety of diseases, as pneumonia, pleurisy, 
and neuralgia, but regardless of its cause, requires anodynes 
for its cure. Hemorrhage, whether from the lungs, the 
stomach, the uterus, or the bowels, depending on different 
organic or general diseases, calls alike for gallic acid, ergot, 
and the like. An exhausting diarrhoea occurs in quite oppo- 
site states and may be very properly controlled by opium, etc., 
regardless of the particular disease ; sleeplessness, occasioned 
by very diverse causes, calls alike for chloral, morphia, etc. ; 
debility, regardless of its cause, is treated properly with 
nutrients and restoratives ; and an exalted temperature of 
the body, whether inflammatory or typhoid, with antipyretics. 
Symptoms, and not the names of diseases, are treated by 
intelligent practitioners, with the exception of those treated 
by specifics as before stated. 

In the diseases which we call Membranous, and which only 
are the subjects of this volume, we observe a common diag- 
nostic symptom or manifestation. It is not pain, nor diar- 

VII 



VIII INTRODUCTION. 

rhoea, nor hemorrhage, nor hyperpyrexia, nor debility, but a 
peculiar exudation from the blood, generally upon mucous 
surfaces, denominated false membranes. These membranes 
are so nearty identical in structure and materials as to render 
a distinction nearly or quite impossible. 

As we shall have occasion hereafter to note, their appear- 
ance has been attributed to both local and general causes, 
which are possibly so obscure, remote, or ethereal, as forever 
to elude discovery. What we wish hereto observe is, simply 
that these diseases, having a like prominent and diagnostic 
symptom, may rationally be treated by the same or similar 
remedies without the violation of any principle entitled to 
professional respect. 

It is but reasonable to infer, from the identity of these 
plastic exudates, that some similar S3 T stemic disturbance 
exists in each of these diseases ; and yet this is only in- 
ferential. Many regard croup and plastic bronchitis as 
purely of local origin from the lack of early constitutional 
symptoms ; while others, equally honest and intelligent, 
observe that common acute inflammation in the same local- 
ities is not ordinarily attended by the membranous exudation, 
and therefore conclude that in these, as in diphtheria, there 
probably exists primarily some peculiar toxaemia. 

Neither of these theories is thought to be entitled to, or 
should be given, any particular influence by the practitioner 
in deciding upon his therapeutical measures at the bedside, 
and hence they are dismissed for the present without discus- 
sion for matters of a more practical nature. 

AUTHOR. 






DIPHTHERIA. 



CHAPTER I. 
DEFINITION. 

Diphtheria is an acute, specific, contagious, febrile disease, 
which occurs epidemically, endemically and sporadically, in 
most countries of the world, and is characterized by general 
or constitutional symptoms like other pj^rexial diseases, with 
a greater or less degree of inflammation of the mucous mem- 
brane of the pharynx, larynx, air passages, or other mucous 
passages ; and by the formation on the surfaces of these 
parts, particularly upon the mucous membrane of the pharynx 
and upper air passages, of a lympho-fibrinous membrane, 
generally in patches of a whitish, yellowish, or grayish color. 

It is further characterized by more or less inflammatory 
swelling of the glands of the throat and neck or adenitis. 

During the prevalence of diphtheria, wounded, abraded, 
or ulcerated surfaces, upon any part of the body, frequently 
become covered with a membranous deposit similar to that 
in the more ordinary situations. The constitutional sj-mp- 
toms usually denote a depressed state of the vital powers. 
Often the urine becomes albuminous from renal disturbance. 
The sequelae most common are lesions of the nervous system 
causing a greater or less degree of paralysis, impairing in 
proportion, phonation, deglutition, respiration, sensation, etc. 
Fatal cases usually terminate by gradual apnea ; less fre- 
qently by asthenia and cardiac thrombosis. 

(i) 



2 DIPHTHERIA. 

CHAPTER II. 
NOMENCLATURE. 

The term diphtheria is of Greek origin, and maj^ properly 
be defined b} T the English term membrane. Diphtheria, diph- 
therite, and diphtheritis are ail used as synonyms, and have 
the same origin. 

Diphtherite, as applied to the disease under consideration, 
was origin all}' emplo3 T ed by M. Bretonnau, a celebrated 
French physician, in his work entitled " Traite de la Diph- 
therite," published in Paris in 1826. Trousseau, considering 
the term objectionable because of the termination ite, used in 
medical science to imply inflammation, changed the word to 
diphtherie, in order to get rid of the aetiological doctrine of 
inflammation expressed b} r the suffix ; and, technically speak- 
ing, diphtheria is the English synonym of the French diphtherie. 

Among ancient writers the disease received a varity of 
apellations, as ; ulcus Egyptianum vel Syriacum — the Eg}*p- 
tian or S} T riac ulcer; angina gangrenosa — gangrenous sore 
throat ; morbus suffocans vel strangulatorius — suffocating or 
strangulating sickness ; garotillo — throat disease ; angina 
suffocativa — suffocating sore throat ; malum canna — throat 
sickness ; and many others. 



CHAPTER III. 
HISTORY. 

(compiled from the best authors.) 

It is not the purpose of the writer, nor within the scope of 
the present volume to enter exhaustively into the bibliography 
of diphtheria. This alone would fill a volume, and could not 
be made profitable to the laborious practitioner of medicine, 
for whom alone, in the interests of humanity, this treatise is 



HISTORY. 3 

designed. The following epitome of what is known on the 
subject is derived from a careful study of the best authorities, 
and may be regarded as authentic. 

Diphtheria, or throat affections in some respects analagous 
to it, can be traced to a remote antiquity ; their identity with 
the modern disease is, however, often, only imaginary, or 
inferred from the resemblance of a few symptoms. There 
are no proofs of any epidemic prevalence of the disease as it is 
seen at the present time, until about the middle of the eigh- 
teenth century. 

Among the more ancient medical records quoted by 
writers in proof that the ancients were acquainted with this 
affection are the following. Nearly twenty-five hundred years 
ago, or about the time of Pythagoras, an East Indian physi- 
cian, named D'hanvantare, gave a description of a disease, 
thought by some to have been diphtheria, in which "An 
increase of phlegm and blood causes a swelling in the throat, 
characterized by panting and pain, destro3-ing the vital 
organs, and incurable : — a large swelling in the throat 
impeding food and drink, and marked by violent feverish 
symptoms, obstructing the passage of the breath, arising from 
phlegm combined with blood, is called closing of the throat." 

Galen of Pergamos, about the middle of the second cen- 
tury, speaks of a membranous formation in the pharynx being 
ejected by expectoration. Aretseus of Cappadocia, a physician 
of renown who practiced at Rome about the time of Augustus, 
has left a history of the Eg}^ptian or SjTiac ulcer, considered 
to have more points of resemblance to the diphtheria of 
to-day than any other disease of antiquity. This was charac- 
terized by ulcers on the tonsils, some mild and harmless, 
while others were pestilential and fatal. " The former, which 
are common — are clean, small, and superficial, and are un- 
accompanied by either pain or inflammation. The latter, 
which are rare — are extensive, deep, putrid, and covered 
with white, livid, or blackish concretion. If it extends 



4 DIPHTHERIA. 

rapidly to the chest through the windpipe, the patient dies 
on the same day by suffocation. 

Ccelius Aurelianus, writing about the close of the third 
century, " describes the barking sound of the voice and its 
occasional complete extinction, the stridulous breathing, and 
lividity of the face. His reference to the defective articula- 
tion sometimes present, and to the passage of fluids into the 
nose in swallowing, probably refer to the paralytic symptoms 
of the disease. It is supposed by some that the Askara 
frequently mentioned in the Talmud as a fatal epidemic, was, 
in fact, diphtheria. Rashi, the learned commentator of the 
Talmud and Old Testament, remarks with reference to the 
Askara, that sometimes it breaks out in the mouth of a man 
and he dies from it. 'Also that sudden death ensues from 
suffocation.' " (Mackenzie.) 

" Macrobius speaks of a similar epidemic at Rome, A. D. 
380, during which, sacrifices were offered up to a certain 
Goddess — ut populus Romanus, morbo, qui angina dicitur 
promisso voto, sit liberatus." (Slade.) "Aetius, of Amida, 
in the sixth century delineated the disease as presenting 
white and ash-gray spots in the pharynx, slowly ending in 
ulceration." (Mackenzie.) 

Brief and unsatisfactory as are the preceding quotations, 
they are believed to constitute the bulk and basis of the 
evidence extant that the ancients were acquainted with this 
malady. From the sixth to the latter part of the sixteenth 
century, nothing further in medical history is noted as 
having any very probable reference, or clear analogy to this 
disease. Hecker's accounts of the epidemics of the four- 
teeth, fifteenth, and sixteenth centuries, in Holland, France, 
and England some of them characterized by violent anginose 
affections, quoted by Slade to connect the ancient and 
modern records of the disease, must be considered irrelevant, 
and wanting in any recorded appearance or symptom charac- 
teristic of genuine diphtheria. . 



HISTORY. 

Of modern writers, Bailou, a distinguished French physi- 
cian, whose writings bear the date 1576, is believed to be the 
first who makes distinct mention of a false membrane. In 
the early part of the 17th century an. epidemic angina, denom- 
inated garrotillo prevailed in Spain. Its best description is 
by Villa Real, who states that he has seen "a thousand 
times, in patients at the first onset of the disease, a white 
matter in the fauces, gullet, and throat. He adds that the 
matter is of such nature, that if you stretch it with your 
hands it appears elastic, and has properties like those of wet 
leather — facts which he noticed, not only by observing the 
matter coughed up by the living, but also by the examination 
of it in the dead." 

About the same period, accounts of the disease, less satis- 
factory because of the omission of the post-mortem appearan- 
ces, were written by Herara and Fontecha. They, however, 
confirm the prevalence of garrotilla (diphtheria) in Spain 
between the years 1581 and 1611. The name "garrotillo" 
was first given the disease because those attacked by it 
perished as if strangled by a cord. In 1617 diphtheria was 
prevalent in an epidemic and fatal form at Naples and in 
other parts of Italy. (Sgambatus.) It was sometimes called 
"Male-de-canna" — disease of the trachea. It continued its 
ravages for a period of at least twenty years, and has been 
described by several other writers of authority, as, Carnevale, 
Zacutus Lusitanius, and Marcus Aurelius Severinus. " Carne- 
vale in particular has given us full data of this epidemic in 
his treatise entitled 'de Epidemico Strangulatione Affectu.' 
The children were first attacked, the disease afterward spread- 
ing among the population generally, and proving very fatal, 
The disease commenced by mild inflammation of the throat ; 
soon the affected parts presented a whitish exudation ; the 
breath became fetid ; deglutition impossible ; the respiration 
embarassed, and the patient died of suffocation. This writer 
also gives us the different appearances which the pharynx 



6 DIPHTHERIA. 

presented in this epidemic ; he also speaks of the extension 
of the disease to the trachea, oesophagus, and pituitary mem- 
brane ; — of the diagnosis, prognosis, and the topical remedies, 
all of which are quite in accordance with modern views" 
(Slade). Carnevale also asserts its identity with the disease 
which had been prevailing in Spain under the name of 
garrotillo. 

In 1625 the writings of Cortesius show that the same 
disease extended, a little later, to Sicily. He speaks of a 
membrane in the throat, which could readily be torn away, 
as being one of its characteristics. In 1632 Alaymus pub- 
lished a treatise upon the Syrian ulcer. He prefers this 
term, he says, inasmuch as it applies to all forms of the 
disease, which he describes in a manner similar to Carnevale. 
" In 1713 Dr. Patrick Blair, of London, in a letter to Dr. Mead, 
described a disease as ' the croops ' which, he says, was epi- 
demic and universal at Coupar Angus, and which was no 
doubt diphtheria." (Mackenzie). 

From 1743 until 1748 the disease prevailed in Paris, and 
has been described by Malouin and Chomel. About the 
same date G-hisi describes an epidemic of the disease in 
Palermo, and noticed the paralytic sequelae. Also about the 
same time a similar epidemic appeared both in England and 
at Cremona, accounts of which were given by Fothergill, 
Starr, and G-hisi. These epidemics were very destructive, 
especially in England, where it was regarded by Fothergill as 
scarlatina. He says, " If the mouth and throat be examined 
soon after the first attack, the uvula and tonsils are found 
swelled ; and these parts, together with the velum-palati and' 
pharynx, appear of a bright red color, which is most marked 
on the posterior edge of the palate, in the angles above the 
tonsils, and upon the tonsils themselves. Instead of redness, 
a broad spot or patch of an irregular form, and of pale white, 
is sometimes seen surrounded with florid red, which whiteness 
appears like that of the gums immediately after being pressed 



HISTORY. 7 

with the fingers, or as if matter ready to be discharged was 
contained beneath. G-enerally on the second day of the 
disease, the face, neck, hands, and breast, are of a deep 
erysipelatous color, with a sensible tumefaction. A great 
number of small pimples, of a color more intense than that 
which surrounds them, appear on the arms and other parts." 
(In a note he says, " The eruption and redness have not so 
regularly accompanied the disease during the latter part of 
this Winter, 1754, as they did last year. In some cases they 
did not appear at all, in others not till the third or fourth 
day.") " The appearances in the fauces continue the same, 
except that the white places become more ash-colored ; and 
it is now found that what might have been taken for the 
superficial covering of a suppurated tumor, is really a slough, 
concealing an ulcer. Instead of the slough, in mild cases, a 
superficial ulcer, of an irregular form, appears in one or more 
parts, scarce to be distinguished from the sound, but by the 
irregularity of surface which it occasions. Towards night, 
heat and restlessness increase, and a peculiar kind of delirium 
comes on, the pulse is generally very quick ; in Some hard 
and small ; in some soft and full. The tongue is generally 
moist, and not often found coated. In some it is covered 
with a thick white fur ; and these generally complain of 
soreness about the root of the tongue." (Slade.) 

" In 1749 Marteau de Grandvilliers described an outbreak 
of the disease in Paris, and the elder Chomel, in detailing 
the symptoms, accurately described diphtherial paralysis. 
In 1750 the formation of a membraniform concretion in the 
throat is distinctly described by Dr. Jno. Starr, as occurring 
as an epidemic in Cornwall, England." (Mackenzie.) 

In 1757, Dr. Huxham in a treatise denominated "A Disser- 
tation on the Malignant Ulcerous Sore Throat," described an 
epidemic which had been prevalent at Plymouth, in which 
some of the cases were undoubtedly of the character of 
secondary diphtheria. "Not only," says-he, ; ' were the nos- 



8 DIPHTERIA. 

trils, fauces, &c, affected, but the windpipe itself was much 
corroded, and pieces of its internal membrane were spit up." 

" Dr. Starr, of Liskeard, published a paper in the Philo- 
sophical transactions, upon the malignant ulcerous sore throat 
epidemic which appeared in that place in 1749. In this 
paper, besides other details of the epidemic, he gives the 
full data of a case in which the false membrane commencing 
in the fauces, extended to the larynx. He particularly dwells 
upon the physical properties of the exudation, its adherence 
to the subjacent surface, its frequent detachment and repro- 
duction. In fact, he gives a complete picture of Bretonnau's 
diphtheria." 

In 1789, Dr. Samuel Bard of Philadelphia, in a work en- 
titled, "Researches on the Nature, Causes, and Treatment of 
Suffocative Angina," gave a detailed account of " an uncom- 
mon and highly dangerous distemper " which had recently 
proved fatal to many children in New York. He recognized 
the analogy between this disease and croup, as well as the 
manner in which it spreads from the throat to the larynx. 
He observed it sometimes as simple angina ; sometimes as 
angina complicated with laryngitis, and occasionally as lar- 
yngitis alone. 

" In general the disease was limited to children under ten 
years of age, though some few grown persons, particularly 
women, had symptoms very similar to it. Most of the per- 
sons attacked were observed to droop before they were con- 
fined. Usually the first symptoms were a slightly inflamed 
eye, a livid countenance, and slight eruptions upon the face. 
At the same time, or very soon after, those who could speak 
complained of an uneasy sensation in the throat, but without 
much soreness or pain. Upon examination, the tonsils 
appeared swelled and highly inflamed, with a few white 
specks upon them, which, in some cases, increased so as to 
cover them all over with one general slough ; this, however, 
although a frequent symptom, did not invariably attend the 



HISTORY. 9 

disease. The breath was not offensive, and deglutition but 
very little impeded. 

" These symptoms continued in some cases for five or six 
days without creating any alarm; in others, a difficulty of 
breathing came on within twenty-four hours, especially dur- 
ing sleep, and was often suddenly increased to such an 
extent as to threaten immediate suffocation. Generally it 
<?ame on later, increased more gradually, and was not constant. 

" This stage of the disease was attended with a very great 
and sudden prostration of strength, a very peculiar, hollow, 
dry cough, and a remarkable change in the tone of the voice. 
In some the voice was almost entirely lost, and would con- 
tinue ver}' weak and low for several weeks after recovery. 
These symptoms continued for one, two, or three days, and 
greatly increased in those who died ; purging in several 
cases came on, the difficulty of breathing became more 
marked, and the patient died apparentl} T of suffocation. 
This commonl} T happened before the end of the fourth or 
fifth day. One child, however, lived under these circum- 
stances to the eighth day. Shortly before he died, his 
breath and expectoration were somewhat offensive ; but this 
was the only instance in which I could discover anything 
like a disagreeable smell, either from the breath or expec- 
toration. 

" In some cases instead of the difficulty in respiration, 
ver} T troublesome ulcers appeared behind the ears. 

" ' These began with a few red pimples, which soon ran 
together, itched violently, and discharged a great deal of 
ver}^ sharp ichor, so as to erode the neighboring parts, and 
in a few days spread all over the back part of the ear, and 
down upon the neck.' 

" In a few cases swelling of the parotid and sublingual 
glands was noticed. Dr. Bard says : — 

" ' I met with but two instances of anything like this 
complaint in adult persons. Both of these were women, and 



10 DIPHTHERIA. 

one of them had assisted in laying out two of the children 
that had died with it. At first her symptoms resembled 
rather an inflammatory angina ; but, about the third day, 
the tonsils appeared covered in some places with sloughs : 
her pulse was low and feeble ; she had a moist skin, a 
dejection of spirits, and some degree of anxiety, though 
nothing like the difficult breathing of the children. 

" '• The other was a soldier's wife ; who, for some time, 
before she perceived any complaint in her throat, labored 
under a low fever. Her tonsils were swelled and inflamed, 
and covered with sloughs resembling those of the children * 
but her breath was more offensive, and she had no suffocation. 

u ' I have had an opportunity of examining the nature and 
seat of this disease from dissection in three instances. One 
was a child of three years old. Her first complaint was an 
uneasiness in her throat. Upon examining it, the tonsils 
appeared swelled and inflamed, with large white sloughs 
upon them, the edges of which were remarkably more red 
than the other parts of the throat. She had no great sore- 
ness in her throat, and could swallow with little or no diffi- 
cult} 7 . She complained of pain under the left breast ; her 
pulse was quick, soft, and fluttering. The heat of the body 
was not very great, and her skin was moist ; her face was 
swelled ; she had a considerable prostration of strength, with 
a very great difficulty of breathing ; a very remarkable 
hollow cough, and a peculiar change in the tone of her voice. 
She was exceedingly restless ; was sensible, and when asked 
a question, would give a pertinent answer ; but otherways r 
she appeared dull and comatose. All these sj-mptoms con- 
tinued or rather increased till the third night, on which she 
had five or six loose stools, and died early in the morning. 

" l Upon examining the body — which was done on the 
afternoon of the day she died — I found the fauces, uvula, 
and root of the tongue interspersed with sloughs, which still 
retained their whitish color. Upon removing them, the parts 



HISTORY. 11 

underneath appeared rather pale than inflamed. I perceived 
no putrid smell from them, nor was the corpse in the least 
degree offensive. The sesophagus appeared as in a sound 
state. The epiglottis was a little inflamed on its external 
surface ; and on the inner side, together with the inside of 
the whole larynx, was covered with the same tough white 
sloughs as the glands of the fauces. The whole trachea, 
from the larynx down to its division in the lungs, was lined 
with inspissated mucus, in form of a membrane, remarkably 
tough and firm ; which, when it came to the first subdivisions 
of the trachea, seemed to grow thin and disappear. It was 
so tough as to require no inconsiderable force to tear it, and 
came out whole from the trachea, which it left with much 
ease ; and resembled, more than anything, both in thickness 
and appearance, a sheath of thin chamois leather. The 
inner membrane of the trachea was slightly inflamed ; the 
lungs, too, appeared inflamed, as in peripneumonic cases, 
particularly the right lobe, on which there were many large 
livid spots, though neither rotten nor offensive ; and the left 
lobe had small black spots on it, resembling those marks left 
under the skin by gun-powder. Upon cutting into any of 
the larger spots which appeared on the right lobe, a bloody 
sanies issued from them without frothing.' " 

11 He supposed the prevalence of the epidemic to depend 
upon the state of the air or a peculiar miasm " which more 
or less, according to particular circumstances, generate an 
acrimony in the humors and dispose them to putrefaction ; 
and which have a singular tendency to attack the throat and 
trachea, affecting the mucous glands of these parts in such a 
way as to occasion them to secrete their natural mucus in 
greater quantities than is sufficient for the purposes of 
nature, and which in this particular species, when secreted, 
is really either of a tougher or more viscid consistence than 
natural, or is disposed to become so from rest and stag- 
nation." 



12 DIPHTHERIA. 

Dr. Bard, says Mackenzie, was a careful and painstaking 
observer, and his monograph contributed very considerably 
to the accuracy of contemporary knowledge of diphtheria ; 
to which we might truthfully add that it is the model after 
which have been constructed most of the descriptions of 
diphtheria which have since appeared, both in this country 
and in Europe. 

In 1802 appeared the "First lines in the practice of 
Physic," by Dr. Cullen, professor of the practice of physic 
in the University of Edinburgh, in which, under the title 
"cjrcanche trachealis" is to be found a description thought to 
be characteristic of the diphtheria of to-day. 

In 1826 appeared the works of M. Bretonneau. These 
owed their origin to the alarming outbreak of the disease 
among the soldiers in the barracks at Tours in the latter part 
of 1818, spreading from thence to the surrounding country. 
In Tours most of the victims were children, and the larynx 
most frequently affected, while among the soldiers the gums 
were the favorite seat of the diphtheritic exudation. Bre- 
tonneau describes the disease in Tours as mild at the com- 
mencement, but becoming alarmingly severe in a few days, 
and very fatal. From thence it spread to two small villages 
adjoining, and thence throughout France. In some towns, 
remarkable for their salubrity and good sanitary conditions, 
it raged violently, while others situated in low marshy 
regions, almost entirely escaped. Elsewhere it seemed to 
select ill-drained localities, and pass over those in better 
sanitar}^ conditions. As evidence of its virulence a case is 
mentioned in which out of seventeen persons in a single 
farmhouse, thirteen died of the disease. 

In Edinburgh, in 182(5, the disease prevailed as a fatal 
epidemic, and was accurately described as " diphtherite " by 
Dr. Abercrombie, in his work on "Practical Researches on 
Diseases of the St6mach, ,r published two years later. 

After the subsidence of the notoriety Bretonneau gave 



HISTORY. 13 

diphtheria, it attracted but little attention for several years, 
till in 1841 an epidemic in the Children's Hospital in Paris 
brought it again before the profession. This epidemic was 
described by M. Becquerel. The children of the institution 
were attacked with sore throat, often attended with mem- 
branous exudation, sloughing, and gangrene. The disease 
was not limited to the faucial and laryngeal surfaces, but 
appeared also upon abraded and blistered cutaneous surfaces. 
He noted also a remarkable state of the blood in its want 
of coagulability. 

During the following fifteen years diphtheritic epidemics 
prevailed from time to time in various parts of Europe, 
especially in France, and were described by Empis, Lemoine 
Jobert and Lespiaen. Dr. Ernest Hart, of London, ably 
described the great English epidemic of 1858-1859. The 
first case was supposed to have been imported from Bolougne 
(probably a relic of the fatal epidemic there in 1855) to 
Folkstone in 1856. Assuming alarming malignancy in 1858, 
it spread widely ; was very fatal during the following } T ear, 
and for three years more continued prevalent. The local 
name was " Throat fever." 

In 1856 an epidemic of this disease prevailed in San 
Francisco and other California towns, and was described by 
V. Fogeaud in an essay on diphtheria and by Dr. Jas. Blake, 
of Sacramento. The mortality was very great. 

About the same date, Dr. Beardsly of Milford, Conn., 
described a fatal epidemic of diphtheria in that and adjoin- 
ing towns, in which the first s} 7 mptom almost uniformly was 
pain in the ear a day or two in advance of any other mani- 
festation of the disease. 

In 1858-diptheria prevailed in Albany, N. Y., and in many 
other towns, and may be said to have been constantly prev- 
alent from that period to the present time, not only in this 
county, but also in England, France, Germany, and most 
other countries of the globe ; and is amply discussed in the 



14 DIPHTHERIA. 

books on general practice, and in monographs, of recent 
date, to be found in the library of every physician. 

A complete history of the medical treatment of diphtheria 
would constitute one of the curiosities of medical literature 
— more curious than instructive. The terrible fatality which 
has attended the disease, seemingly little abated by any treat- 
ment hitherto practiced, has led to the exhibition of almost 
every known remedy; but failure still incites to laudable 
research and trial of new remedies. 

Such conditions have caused discrepancy and distrust, and 
have led many practitioners of eminence to ignore authori- 
ties, to discard precedents, to repudiate so-called specifics, 
and to treat the disease on general principles, or as the 
symptoms occurring in any case might seem to demand. 
Confusion and doubt here, as generally, precede order and 
confidence. 

The therapeutical history of the disease, although not 
intended to constitute an integral part of this treatise, will 
of necessity, be somewhat developed when we come to speak 
of treatment in chapters 16 and 17. 



CHAPTER IV. 
CAUSE. 

It is found exceedingly difficult to define disease itself, and 
is much more difficult to discover or define its cause or 
causes. The cause of certain fevers is said to be malaria, 
but what is malaria ? Malaria is a subtile miasm, or micros- 
copic entity or vapor, exhaled under certain imperfectly 
understood conditions. Its properties, its constituents, and 
its sources, are not perfectly known. If fevers prevail alike 
on either side of a river or morass, who can tell whether the 
miasm is exhaled or attracted ? Neither can we tell certainly, 



CAUSE. 15 

"with any or all the chemical and optical appliances known, 
whether it is animal or vegetable, solid, fluid or gaseous. 
Then, as we have learned but very little of the laws that 
govern it, doubtless the part of wisdom is to call it a "subtile 
entity," bej^ond the borders of the visible, and beyond the 
range of inductive philosophy. We have defined diphtheria 
as a contajious disease, and scientists have, for these many 
years, been searching for the entity which we denominate the 
contagium, in hopes that its discovery might guide in the 
discovery of a logical specific remedy. As Salisbury believed 
that he had discovered the true cause of malarial disease to 
be a minute vegetable organism, so also Oertel, Heuter, 
Nasseloff, Eberth, and other German investigators claim to 
have discovered and demonstrated the cause of diphtheria to 
be also minute vegetable growths which are denominated 
Bacteria, and divided into several genera and species. 

Any overestimate of the importance of such a discovery, 
as tending to throw light upon the nature and treatment of 
the malady is nearly impossible. If, on the other hand, the 
supposed discovery is not sustained by observation and 
scientific research, it may equally tend to obscurity and 
wrong theor} T , and pernicious treatment. It seems., there- 
fore necessary in any treatise upon diphtheria, in view of the 
powerful advocacy of the bacterian theory by eminent scient- 
ific writers as the above, and the great influence given to the 
theory by the recent publication 6f Prof. Ziemssen's C} 7 "^- 
pedia, to somewhat carefully examine its claims, that we 
may award it all, and only the merit and influence to which 
it is justly entitled. The following summar}', it is believed, 
gives as correct and authentic a view of this German theory 
as can be presented in the space allotted. 

Two of the numerous species of bacteria, called micrococci, 
or spherical bacteria, and micro-bacteria, or rod-like bacteria, 
are supposed either to constitute the disease germs of diph- 
theria or to be its carriers from one person or locality to 



16 DIPHTHERIA. 

others — fo constitute the real contagium. By means of the 
most powerful microscopes most skillfully manipulated, these 
minute bodies "just on the borders of the visible" are seen 
only as minute specks, or as oscillating points. 

" In every tissue affected with diphtheritic inflammation, in 
ever} 7 diphtheritic false membrane, and, in severe cases, in 
the blood, the tissues, and excreta, are found large numbers 
of micrococci, associated with a smaller number of micro- 
bacteria, which increase or diminish in the ratio of the 
violence of the disease. They accumulate vastly just before 
the formation of the exudation upon any abraded or wounded 
surfaces of patients ; especially on the edges of the wound 
produced by tracheotomy. 

If any mucous surface exposed to the air, or any abraded 
cutaneous surface, being the seat of inflammation and occu- 
pied b}' other forms of bacteria, as the leptothrix buccalis, or 
oidium albicans, is attacked by the diphtheritic form of 
inflammation, these bacteria at once disappear, and are 
succeeded by the sphero and micro-bacteria. Again, when 
the diphtheritic disease abates, these latter disappear and are 
succeeded by the former. 

In the early stages of the disease the grayish spots upon 
the phar3 r ngeal surfaces are found to consist entirely of these 
bacteria, epithelial cells, and mucus, and in the later stages 
only are associated with pus and fibrin, as resultants of 
inflammatory reaction. 

In order more clearly to ascertain the relations of these 
bacteria to diphtheria, recourse was had to various carefully 
conducted experiments. Croupous inflammation of the 
mucous membrane of the larynx was induced by the applica- 
tion of a powerful irritant (ammonia) producing a croup-like 
membrane. Although the fibrous exudation afforded a soil 
which varied little, or not at all, in its histological composi- 
tion from that induced by diphtheria, none of these organisms 
were found upon nor beneath the inflamed surfaces. 



CAUSE. 17 

In further experiments upon animals, inoculations with, 
diphtheritic matter were practiced upon the mucous membrane 
of the air passages, the cornea, and muscles, with the result 
of inducing a rapid increase of these diphtheritic. bacteria 
(the micrococcus and micro-bacterium) which rapidly pene- 
trated the tissues and induced systemic infection. 

Oertel says, " I have noticed in numerous inoculations, that 
if various bacteria besides the micrococcus, as for instance, 
bacillus, spirillum, and bacteria lineolum, were present in the 
matter to be inoculated, only micrococci (sphero-bacteria) 
and the bacterium termo (in its most minute forms accom- 
panying them) showed evidence of prolific growth, while all 
the other forms disappeared altogether." 

Upon the cornea these inoculations produced a vast multi- 
plication of these bacteria, violent local disease, systemic 
infection, and death. 

Oertel says, "according to my experiments, the bacteria 
spread over the mucous membrane of the trachea, beset the 
cellular elements, crowd especially into the young exudation 
cells, or are taken up by them, and' gradually cause their dis- 
solution ; they fill the blood and lymph-vessels, and bring 
about in a mechanical way, a damming up of the fluids, and, 
as a consequence, serous exudation. As they close up the 
capillary vessels, they occasion stagnation in the blood cir- 
culation, which induces disturbance of nutrition in the walls 
of the capillaries, and even rupture of the same. Muscular 
fibres, also, which are covered and filled with colonies of 
micrococci, degenerate and slough ; in like manner, in severe 
cases, immense numbers of bacteria appear heaped up in the 
uriniferous tubules and Malpighian corpuscles of the kidneys, 
and occasion there parenchymatous inflammation, capillary 
embolism of the glomeruli of the kidney, with ruptured ves- 
sels and formation of epithelial casts of the tubes. In the 
lymph and blood streams (compare also Hueter), in long con- 
tinued sickness of the animal experimented on, these bacteria 



18 DIPHTHERIA. 

also accumulate in masses. They induce, as excitors of de- 
composition and disorganization of organic nitrogenized 
bodies, septicaemia, through the vegetative process they un- 
dergo, and through their relation to oxygen." 

From the foregoing it would be a necessary induction 
that these organisms, wherever they exist in any consider- 
able numbers in proximitj^ to human beings or other animals, 
must cause diphtheria, and that the disease could not prevail 
without their agency. Indeed Eberth, one of the leading 
advocates of this theor3 T , declares that " without micrococci 
there can be no diphtheria." 

Diphtheria, then, and micrococci, according to this theory, 
must, or should be, coexistent and coextensive. A trial of 
the theory by this rule certainly is not open to the charge of 
unfairness. Eberth's assertion, "without micrococci there 
can be no diphtheria," is only the logical sequence of the 
bacterian theory ; and, from the same stand-point it is equally 
logical, and, indeed, fundamentally necessary to the support 
thereof, to reason that wherever and whenever this bacterian 
cause exists, its effect, diphtheria, should occur in the case 
of nearly every exposed person, as cause and effect are in- 
separable ; and yet it is true that not even a majority of those 
most exposed contract the disease. 

During epidemics of the disease, according to the views 
of those holding the theory of Eberth, the superabundance 
of these entities, especially in the presence of the sick, where 
they must be continually inhaled by the attendants, should 
make infection the rule : the actual general exemption from 
infection, shows, not only the general innocuousness of bac- 
teria, but may be regarded as an intimation of their utter 
harmlessness to persons in health, a doctrine held b}' many 
critical observers. Such comparative exemption, regardless 
of exposure, is not true of the other contagious diseases of 
childhood, as scarlatina, rubeola, pertussis, etc. ; and even if 
it were, would avail nothing in support of the theory unless 



CAUSE. 19 

it could be shown that the}", too, were the effect of bacterian 
or similar infection. 

If upon a congenial soil we sow seed in proper season, it 
straightway germinates and grows through its several stages 
to maturity ; and like results are almost certain to follow if 
the seed be sown upon any number of fields. Now suppose 
the field to be the pharynx, and the seed, living bacteria 
germs ; can any reason be given why the crop should fail in 
a majority of cases even during the epidemic prevalence of 
diphtheria ? This point may be still further exemplified by 
reference to the habits of another of the microscopic fungi, 
the torulse cerevisise, or yeast plant. Its soil is chiefly the 
mash or malt of the distiller and brewer, which, by its in- 
strumentality, is converted largely into alcohol. Wherever 
this soil with the proper conditions of warmth and moisture 
exist, thither almost invariabty the germinal matter or seeds 
of this fungus are attracted, and the whole mass speedily is 
pervaded by its developing and developed progeny. Here 
failures rarely occur. It is, at least, presumable that the 
pharyngeal mucous membrane, in a condition of health is a 
soil nearly always, if ever, in a condition to favor the develop- 
ment of these microzymes, or bacteria germs, and their rapid 
multiplication ; therefore, as in the mash, the results should 
be very nearly uniform, and infection be the rule instead of 
the exception. It is certain that no peculiar state of the 
mucous membrane has been, or is likely to be discovered, 
which insures exemption from, or specially predisposes to the 
disease. If the bacterian theory is at all tenable, all persons 
of the same age, with like sanitary surroundings, by exposure 
must be equally liable to contract the disease, and should 
uniformly become infected, were the cause the lodgment of 
these germs upon the pharyngeal mucous surfaces. As 
this is not the case, from reasons before indicated, we judge 
that the theory lacks in essentials, and is not worthy to in- 
fluence our pathological views or therapeutical measures. 



20 DIPHTHERIA. 

That the contagmm or disease germs of the contagious 
diseases is living matter is neither contested nor conceded, 
but it is not probably a consequence of the development 
upon any part or within the system, of microscopic fungi, or 
packs of micrococci. 

On this point Dr. Lionel Beale further remarks, " We must 
not, however, conclude that if disease germs really do consist 
of living bioplasm or germinal matter, they must necessarily be 
of a vegetable nature, and have sprung from vegetable organ- 
isms, or have originated spontaneously, for it is obviously 
possible, that, though living, their nature maj r be very differ- 
ent, and they may have been derived from a different source. 
While I freely admit that the facts of the case are conclusive 
as regards the living state of the active matter of contagious 
diseases, I am quite unable to subscribe to the arguments 
advanced in favor of the vegetable germ theory of disease" 
For a full discussion of these theories, the reader is referred 
to Beale on Disease Germs. 

Bacteria, whose forms cannot be distinguished from the 
micrococci, are to be found in abundance whereA r er and when- 
ever animal decomposition is in progress, and yet often for 
long periods no cases of diphtheria are developed. Bacteria 
germs grow and multiph T whenever a change takes place in 
the solids and fluids of the organism, which develops com- 
pounds suitable for the pabulum of these living bodies. 
From the fact that bacteria grow and multiply, not only in a 
few special fields, but in a great variety of different morbid 
conditions, it is evident they have nothing at all to do with 
any particular form of disease. 

" All attempts to demonstrate various constant species of 
bacteria, representing different contagious diseases — and 
many attempts have been made — have completely failed. 
There is greater difficulty than would appear at first in test- 
ing the matter experimentally, for it is probably impossible 
to introduce bacteria in quantity into the blood of a " healthy 



CAUSE. 21 

animal without at the same time introducing putrescent 
matters which by themselves would occasion the most serious 
derangement. Active bacteria introduced into a healthy 
wound or amongst the living matter of healthy tissues, will 
die, although the most minute germs present, which escape 
death, may remain embedded in the tissue in a perfectly 
quiescent state. Before the bacteria can grow and multiply, 
the death of the higher germinal matter must occur ; as long 
as this lives, it, and the adjacent tissues, are freely permeated 
by healthy fluids, and will efficiently resist their assaults. 

" When pus bioplasts die, and their death occurs when 
they are placed in any fluid which is not adapted for their 
nutrition, the vital movements cease, and the corpuscles 
invariably assume the spherical form. Not unfrequently a 
change occurs in the outer part, and a sort of membrane, 
like a cell wall, is produced ; the contents become more 
granular, and they assume the appearance usually given in 
published drawings. After a short time the matter of which 
they are composed undergoes change, and is invaded by 
bacteria germs, which grow and multiply. These bacteria 
are not formed directly from the matter of the pus which 
once lived, but it is quite possible that bacteria germs existed 
in a living but perfectly quiescent state amongst the oldest 
particles of the ' living matter on the surface of the pus cor- 
puscle when it was yet alive. 

"Bacteria germs less than the 100,000th of an inch in 
diameter can readily gain access to all parts of the organism, 
and probably remain alive, though quiescent, for a long 
while." (Bacteria germs are not bacteria, but only the 
elementary germs from which, as from seed, in favorable con- 
ditions they are developed ; denominated also microzymes.) 
"They may be destroyed in vast numbers in the healthy 
state of the body, though, under certain local changes, the 
conditions become favorable to their development and multi- 
plication. It has not been proved that these bacteria or their 



22 DIPHTHERIA. 

germs, ' microz3 T mes ' have anything to do either with the 
condition of health or disease, and it has been shown that 
they do not necessarily give rise to suppuration, inflamma- 
tion, or other morbid change. Nor has any form of fungus 
germ whatever been proved to produce any contagious fever. 
The fungus germ theory of disease, as already shown, cannot 
be sustained unless many important facts are altogether 
ignored. Nor is it more probable, that the socalled micro- 
z} T mes, which ultimately become bacteria and vibriones, but 
never, according to Dr. Sanderson, result in developing fungi, 
have anything whatever to do with the production or propa- 
gation of contagion. It must be clearly understood that the 
minute particles of bioplasm, described and figured by me in 
1863, and in the second part of this work, are certainly not of 
the nature of microzymes or fungi of any kind whatever ; they 
cannot be called microzymes unless the meaning of the word 
be completely changed. A microzym becomes a bacterium. 
A disease germ has no connection with bacteria, microzymes, 
or fungi, either as regards its nature, properties, or origin. " 
Again, the same author says, " If contagious diseases are 
due to the entrance into the organism of such minute vege- 
table germs as those described, is it not wonderful that any 
one escapes disease ? Multitudes of germs of different species, 
as numerous as are the contagious diseases from which we 
suffer, must, if this theory be true, surround us. And yet 
the fungus germs, which are to be detected easily enough, 
and which indeed do exist in great numbers, are not known 
to cause any disease. Still, upon this view, these must be 
the disease producing particles, for they are the only vege- 
table germs that have been discovered. Passing into our 
lungs with every inspiration, entering our stomachs with our 
food and drink, everywhere in contact with our cuticle, in 
the chinks of which they might grow and multiply, these 
fungus germs must, one would think, pass, in vast numbers 
into our blood, and be carried to every part of our bodies. 



CAUSE. 23 

Contagious diseases ought, therefore, to be more common 
than they are, and escape from attack should be almost 
impossible." (Beale, Disease Germs.) 

Again, according to these authors, i. e. those holding to 
the bacterian theory, diphtheria is at first a local disease of 
the pharynx, air passages, or some denuded surface, and 
thence is developed into a constitutional one by absorption 
of the specific principle into the blood, whereas most prac- 
titioners and authors reverse the order. Constitutional 
symptoms are generally first to appear, and the local follow 
just as is the case in variola, scarlatina, measles, etc. It 
seems quite irrational to ascribe the pyrexial symptoms to 
a local disease that cannot be said as yet to exist. We might 
with equal propriety ascribe the rigors, the cephalalgia, the 
rachialgia, and the fever of the early stages of small pox to 
a cutaneous eruption which we only expect, and which may 
never appear. 

J. Lewis Smith, M. D., of Bellevue Hospital Medical 
College, New York, in his work entitled " Diseases of Infancy 
and Childhood," in reference to the Bacterian theory of 
diphtheria, writes as follows. " With an experienced micro- 
scopist of New York, I have examined the secretions and 
exudations upon the fauces in various cases of pharyngitis, 
both diphtheritic and non-diphtheritic, and we ordinarily 
found the micrococcus in abundance in the inflammatory 
product, whether diphtheritic or non-diphtheritic, a secretion 
or exudation, if it had remained some time upon the surface 
of the fauces. In one case of simple pharyngitis, no bacteria 
could be discovered on the first day in the secretion which 
lay in the depressions over the tonsils, while, on the second 
day, numerous micrococci had appeared. Micrococci, then, 
which are not distinguishable with our present means of 
observation from those in a diphtheritic exudation, may 
occur in great numbers in the secretion of non-specific imflam- 
mations, so that their presence does not afford certain indica- 



24 DIPHTHERIA. 

tion of the diphtheritic disease. It is also well known that 
bacteria, which seem to be identical with those in diphtheria, 
are frequently found upon the gums, and between the teeth 
in health. Moreover, in the intervals of epidemics and in 
localities where diphtheria has not occurred, or has occcurred 
rarely, the microscope discloses the existence of bacteria 
which resemble in form and activity those found in diph- 
theritic products, and in sufficient numbers to justify the 
belief that they frequently pass over the fauces with the 
inspired air. How remarkable, if the bacterian theory is 
true, that fungi, which, under ordinary circumstances are 
innocuous should exhibit the fearful energ} r and destructive 
power which we observe in diphtheria ! It has however been 
suggested to me, that the diphtheritic bacteria may possess 
peculiar functions and properties, since it is very difficult to 
observe differences, which may exist, and classify organisms 
which are just on the borders of the visible. A fact which, 
till it is satisfactorily explained, must, I think, throw doubt 
on the bacterian theory, is that the bacteria do not irritate 
the lungs. If, during inspiration they are carried along the 
current of air, and certain of them lodge upon the fauces, 
where they produce the specific inflammation, a larger num- 
ber must enter the lungs, where we would suppose, from the 
delicate structure of these organs, and their proneness to 
inflammation, they would produce severe results ; so far from 
this occurring, bronchial and pulmonary catarrhs are rare at 
the commencement of diphtheria, and not common at any 
stage of the malady." 

The foregoing and other considerations, it seems to me, 
justify, nay, demand, dissent to a theory at once so novel 
and unsatisfactorj 7 . 

Facts compel the belief in primary constitutional infection, 
whereas this theory makes diphtheria only a local disease 
with constitutional expressions or symptoms. 

That blood-poisoning, toxseemia, is alone capable of indue- 



CAUSE. 25 

ing the phenomena of the cliscease, we may now attempt to 
elucidate. 

The local disease, if it exists at all in the beginning, is 
quite too trivial to induce the s} T stemic derangements so 
generally manifested in the early stages of the disease : as 

a) The chilliness and pyrexia, with the appearance of 
general indisposition. 

b) The increase of temperature, which is often from two to 
six degrees, and sometimes even more. 

c) The accelerated pulse, often reaching 120 to 140. 

d) The prostration, which is often so great in the very 
beginning as to cause the patient to keep his bed. 

e) In malignant cases the great prostration and general 
lividity of the surface, and occasional sudden death with 
almost no throat affection. 

f) The troublesome vomiting and occasional diarrhoea, 
which occur sometimes as the initial symptoms. 

These are indications pointing only to S} T stemic disease, 
and as certainly as the magnetic needle points to the pole. 
They are not all to be expected in an} r one case, but upon 
what other theory can we account for any one of them ? 
They, as before remarked, constitute the initial symptoms, 
and often precede any considerable local disease, as in the 
following case. 

Oliver Fletcher, of 22 Barber ave., Cleveland, 0., a 
laborer about thirtj 7 years of age, suffered severely while 
at work during the day of Oct. 16th, 1883, with violent 
headache, frequent paroxysms of chills and fever, together 
with a feeling of intense fatigue and general indisposition, 
accompanied by anorexia. Patient was visited by the writer 
at 7 P. M., after his return from work. He was in bed 
groaning and exhibiting signs of greac distress and alarm. 
Said he had felt indisposed for several days, in consequence, 
as he thought, of working with wet feet. He had vomited 
twice ; his countenance was suffused and dark, and the nausea 



26 DIPHTHERIA. 

continued. Pulse 110; temp. 104^. He exhibited signs of 
mild delirium, and had violent pains in region of the 
kidnej's, and occasional rigors occasioned by contact of air 
in turning over or rising. Tongue lightly coated, fauces 
moderately injected, not in the least painful ; no signs of 
any exudation, nor complaint of tenderness. Respiration 
hurried and nervous. Urine scanty, and loaded with urates. 
(Not tested for albumen.) Diagnosis reserved. Prescribed 
an alterative cathartic, and three drop doses of tr. veratrum 
viride. 17th, 11 A. M. Less feverish excitement. Pulse 
100; tern {j. 101°. A little less nervous, but complained of 
severe pain in the throat. Examination revealed a mem- 
branous patch ^ by •§ in., on posterior faucial surface, tonsils 
swollen and studded with numerous specks of false mem- 
brane, which rapidl} T increased in size ; twelve hours later 
they had coalesced into large patches. The patient had been 
delirious during the night, but at time of morning visit was 
entirel}' rational. He was put at once upon the chloral 
treatment, and on the 20th was discharged convalescent. 

To the foregoing evidences of primary systemic contamina- 
tion may be added, others derived from the secretions, as 
ichorous discharges from the nares, excessive secretion in the 
mouth and fauces of offensive sticky mucus, suffusion of 
the eyes, &c. These are so often observed among the earliest 
symptoms that I will pass by them as too common to require 
further notice. 

The Kidneys. Albuminuria is frequently observed before 
the blood has had opportunity to become contaminated by 
absorption of decomposed pharyngeal exudation, and there- 
fore can only be regarded as evidence of the priorit}^ of the 
general disease to the local manifestations. Its occurrence 
is not to be regarded as evidence of unusual severity of the 
attack, or of great danger, nor even of disease of the 
kidneys themselves, but is evidently due to the altered 
state of the blood and the rapid waste of tissue, which are 



CAUSE. 27 

very early effects of the poison of diphtheria. Urea, nor- 
mally a principal constituent of the urine, and a product of 
the decomposition of the tissues of the body, is also found 
in excess in the very beginning of diphtheria. This is only 
to be accounted for in the same way as the early occurrence 
of albuminuria, and affords another incontrovertible evidence 
that the disease is primarily general, and not local, as 
claimed by those who uphold the bacterian theory. 

The hyaline and granular casts, which subsequently or 
simultaneously appear in the urine, are to be regarded as the 
consequence of nephritis occasioned by the overwork of the 
kidneys in the excretion of the enormous tissue waste, together 
with the impairment of these organs by the general disease. 

In a paper published in the British and Foreign Medico- 
Chirurgical Review (Jan., 1860), it is affirmed by Mr. San- 
derson, "that diphtheria agrees with the other pyrexiae in 
being attended with a marked increase in the excretion of 
urea, and that the existence in the kidney of the condition 
which is implied by albumen and fibrinous casts in the urine, 
does not necessarily interfere with that increase in the elimi- 
nation of nitrogenous material. There is, therefore, no 
reason to apprehend the occurrence of uraemia as a conse- 
quence of the renal complication in diphtheria ; this compli- 
cation not being the cause of the dyscrasia, but merely the 
index of its existence." 

M. M. Bouchut and Empis, as early as 1858 attached 
great importance and significance to the occurrence of 
albuminuria as especially indicating primary blood-poisoning, 
in which its resemblance to purulent infection, which is 
accompanied by a similar alteration of the urine, is observed. 
On this point M. Bouchut concludes that " albuminuria, in 
the absence of scarlatina or asplryxia (dependent upon 
la^ngeal obstruction), is a sign in diphtheritic disease of a 
commencement of purulent infection, and coincides with a 
very great gravity of the disease." 



28 DIPHTHERIA. 

Sir Jno. R Cormack, of Paris, 1876, asserts that albumi- 
nuria sometimes occurs on the first day of the disease, and, 
necessarily, the nephritis upon which it depends. 

Smith says (Diseases of Children, page 230), " Important 
evidence of the constitutional nature of diphtheria is afforded 
also by the state of the kidneys. No internal organs are so 
often affected in diphtheria as the kidneys, and on account 
of their location and anatomical relation, it is evident, the 
poison first passes through the s}'stem before reaching them. 
An}?- clinical or anatomical fact, therefore, which indicates 
that the diphtheritic virus has reached and affected the 
kidneys, affords proof that it has penetrated the system and 
poisoned the blood. Now the occurrence of albumen, with 
granular or hyaline casts, in the urine, in cases unattended 
by dyspnoea, affords proof of nephritis, caused by the action 
of the poison on the kidneys.'* He also quotes Sir John It. 
Cormack of Paris, and gives the two following cases to con- 
firm the statement quoted, that albuminuria and, of course, 
the nephritis on which it depends, sometimes begins as early 
as the first da} 7 of the disease. 

"Case I. L. McD., aged three years, was first visited by 
me on February 29th, 1876. I learned from the parents that 
she had been feverish during the previous fort} r eight hours, 
and her urine very scanty. A moment's examination was 
sufficient to show that the case was one of malignant diph- 
theria, for the fauces were already nearl}' covered by the 
diphtheritic pellicle, the temperature wan 103^°, and the 
pulse 140. The skin was hot and dr}-, and there was moder- 
ate swelling under the ears, and a muco-purulent discharge 
from the nostrils. On account of the scantiness of the 
urine, the amount not exceeding four to five ounces daily, it 
was impossible to obtain sufficient for examination till the 
next day. It was then found to have a specific gravity 
of 1032, to contain a deposit of urates and hyaline and 
granular casts, a diminished amount of urea ; and a large 



CAUSE. 29 

quantity of albumen. It can hardly be doubted from the 
scantines of the urine, and the large amount of albumen 
found when the urine was first examined, that albuminuria 
had been present on the first day. 

"Case II. The following was a similar case; K., aged 
four years, living in West thirty-sixth street, was visited by 
me in consultation on Jan. 29, 1875. Her sickness had also 
continued forty-eight hours ; her fauces were swollen, and 
covered with the diphtheritic pellicle, which was dark and 
offensive ; respiration guttural ; pulse 120 ; temp. 101°; she 
had a free discharge from each nostril ; urine scanty, its 
specific gravity 1030 ; it contained a small amount of 
albumen, with casts, and a large amount of urates, with no 
apparent diminution of the urea. Death occurred on the 
fourth da} 7 ." 

The false membrane presents still further evidence of the 
constitutional cachexia or contamination of the blood. 
There are but two classes of cases in which it is not present, 
viz, those in which death from blood poison takes place 
before the exudation has time to form, and those in which 
the local disease is not severe enough to cause sufficient 
exudation to form one. 

As before stated, these membranous deposits are often 
formed upon the surfaces of wounds and sores. In nursing 
women they sometimes form upon the nipples. They some- 
times appear at the orifices of the nares, and may form also 
in the lachrymal duct and thence extend themselves to the 
conjunctiva. In a few instances they have been known to 
invade the sesophagus. The surface of the tongue, the 
buccal and gingival mucous surfaces, and, in short, any 
surface of the body open to the air and not covered by a 
thick epidermis, is liable to be invaded. 

It would seem as though in bad cases the virus is so 
abundant that every available point is sought for its expul- 
sion. It is affirmed that the disease only localizes itself at 



30 DIPHTHERIA. 

these several points, and that each is separate from the rest 
and is only a local malady. What, then, becomes of the other 
symptoms alread} 7 alluded to ? How are they, or those still 
more grave that are now so emphatically announced by the 
rapidly failing powers, to be accounted for ? These mem- 
branous patches are evidently exudations mainly from 
beneath, and not merely deposists from above. This is shown 
b} T their similarity to the contents of the inflamed structures 
beneath them. The glands of the throat and neck are stuffed 
with coagulating fibrin abstracted from the blood ; from 
which, in health, it obstinately refuses separation, save for the 
legitimate purposes of nutrition. A little of this fibrinous 
material exudes and immediately coagulates to form the 
basis of the membrane, in the meshes of which, are found 
entangled l} T mph and blood corpuscles, epithelial cells, 
granular matter, micrococci, pus corpuscles, etc. Nearly all 
of these morbid products are of, or from, the blood and are 
therefore demonstrative proof of the primary toxaemia. 

Glandular swellinjs in a large majority of cases are observed 
in the beginning of the attack, before an}' inflammation of the 
faucial surfaces or any exudation has occurred, and is another 
evidence of the primary blood poisoning. " It is not a 
secondar}^ result of the throat manifestations, but belongs to 
the general disease itself." (Sir Jno. R. Cormack.) 

In those cases which are fatal within the first two or three 
days, very often no false membrane has formed, and the 
autops}' reveals only sanguineous congestions of the lymph- 
atics, mucous membranes, and internal organs. In these 
cases the violence of the toxcemia kills, without producing the 
characteristic pellicle. 

Finally, on this point, it may be remarked, that in at least 
two epidemics reported by competent writers, the initial 
S} T mptoms did not relate to the throat. In that of 1789 in 
New York, reported by Dr. Samuel Bard, a slight inflamma- 
tion of the eyes and a livid countenance were generally the 



CLIMATIC AND ATMOSPHERIC INFLUENCES. 31 

first symptoms. In the epidemic in New England in 1856, 
reported by Dr. Beardsley of Milford, Conn., pain in the ears 
preceded by a day or two the other manifestations. In these 
cases to assign as the cause of the pains the lodgment of 
bacteria in the eyes, the ears, or upon the fauces, seems 
puerile. 

Having shown, though not exhaustively, that the so-called 
"bacterian theory" of diphtheria merits little confidence, and 
that the malady is of a general or constitutional character, 
which I designate diphtheritic toxaemia, I am read}^ to confess 
ignorance of the real nature of the virus. That it originates 
in the living organism is most satisfactorily shown in the 
elaborate treatise of Dr. Beale, already quoted, and to which 
the inquirer is confidently referred as the most able, satis- 
factory, and elaborate work on the mooted subject of 
" Disease Germs." 



CHAPTER Y. 
CLIMATIC AND ATMOSPHERIC INFLUENCES. 

Climate exercises no inconsiderable influence upon the 
prevalence of diphtheria, although it prevails to some extent 
in nearly every country. 

It has been observed within the tropics, but never, I 
believe, in the Arctic regions. It is most prevalent in 
temperate climates, neither extreme favoring its prevalence. 
It does exceptionally, however, prevail in all seasons of the 
year. Autumn and Spring seem, in this country, most to 
favor its prevalence. 

I have known the occurrence of extreme heat or cold to 
greatly mitigate the prevalence of an epidemic. 

The germs of diphtheria may remain dormant for a con- 
siderable time external to the body, and then be rendered 



32 DIPHTHERIA. 

active by favorable climatic or atmospheric states, or when 
other conditions, favoring such change, occur. Dr. Thursfield 
found in certain isolated houses and hamlets in England, 
where, in recent years, he had been called to investigate 
cases of diphtheria, that, at intervals of five, ten, fifteen, 
twenty, twenty-five, thirty, and even more years, there had 
been previous outbreaks of fatal sore throat. In Reynold's 
System of Medicine is recorded an instance in which the virus 
remained latent eleven months, and then led to the develop- 
ment of the disease when a person occupied the room, in 
which a case of diphtheria had previously occurred. 

Dr. Mackenzie says, " I have known the poison to remain 
dormant for four, seven, and eleven months, and in one 
instance for three years, and then again to become active." 
Like observations have been made by others, leaving little 
room to doubt the long continuance of the vitality of the 
disease germs. 

In this country the disease in its prevalence pays little 
regard to locality, being as frequently met with in high and 
dry localities as in the valleys or in the vicinity of morasses. 
It is more prevalent in cities and towns than in the country, 
although, according to reliable authority, the reverse is true 
in England, as shown by Dr. Thursfield's observations as 
sanitary inspector of a district extending over 1200 square 
miles, "with a population of a, little over 200,000, of which 
rather more than 100,000 are rural ; the number of fatal cases 
of diphtheria in the rural portion is nearly three times that in 
the urban." 

In Germany, and some other European countries, the 
disease is said to prevail more extensively in winter than at 
other periods of the year. 

Severe epidemics, however, have been known to prevail at 
all seasons, regardless of weather and temperature. Diph- 
theria, then, is practically unlimited by latitude or season or 
altitude. 



MODE OF PROPAGATION. 33 

CHAPTEE VI. 
MODE OF PROPAGATION. 

I have already in chapter I. designated diphtheria as a 
" contagious disease," hence, in brief, its mode of propagation 
must be by contact with the " disease germs," be their nature 
never so obscure or intangible. 

Something is generated within the organism of the infected, 
and disseminated in the air, the water, or the food, which is 
capable within certain limits of conveying the disease to 
others who may be susceptible of a like infection. This is 
what is implied in the phrase " contagious disease." 

That this is the mode of propagation observed in this 
disease, although formerly controverted, is so generally 
admitted at the present time, that little need be said in its 
vindication. 

Bretonneau maintained that the exudation in diphtheria 
possessed a special virulence, and constituted the real virus 
of the disease. He says, " Innumerable facts have proved 
that those who attend patients cannot contract the disease 
unless the diphtheritic secretion in the liquid or pulverulent 
form is placed in contact with the mucous membrane, or 
with the skin on a point denuded of epidermis, and this 
application must be immediate. The Egyptian disease is not 
communicable by volatile, invisible emanations, susceptible 
of being dissolved in the air, and of acting at a great distance 
from their point of origin. It no more possesses this quality 
than the syphilitic disease. If the liquid which issues from 
an Egyptian chancre, as visibly as that which proceeds from 
a venereal chancre, has seemed under certain circumstances 
to act like some volatile forms of virus, the mistake has 
arisen from its not having been studied with sufficient atten- 
tion. The appearance has been taken for the reality." 

He supports this view by citing the following cases. 
3 



34 DIPHTHERIA. 

M. Herpin was surgeon to the hospital at Tours. One da}' 
while visiting a child suffering from diphtheria, during the 
process of sponging the pharynx, in a paroxysm of coughing 
a portion of the diphtheritic matter was ejected from its 
mouth, and lodged in the mostril of M. Herpin. Neglecting 
the removal of this particle, the consequence was a severe 
diphtheritic inflammation which spread over the n ares and 
pharynx. The constitutional sj^mptoms were extremejy 
severe, the prostration great, and ccnvalescence occupied 
more than six months. 

Dr. Gendron received a portion of the diphtheritic exuda- 
tion expelled by a patient during a fit cf coughing, upon his 
lips, in consequence of which he suffered severe laryngeal 
inflammation, and his life was only saved by prompt and 
decided measures. 

A boy affected with frost bite of his foot used a bath that 
had been employed for a diphtheritic patient, and became the 
subject of painful, diphtheritic exudation on the great too. 

Trousseau failed in his attempts to inoculate himself and 
two of his pupils with diphtheritic matter, as did also Dr. 
Harley of London in his experiments on animals. Still M. 
Bretonneau maintained that the virus of diphtheria was only 
transmissible by inoculation. Isambert controverts the 
opinions of Bretonneau, and says, " We cannot reject infection 
at a distance as one of the means of propagation possessed 
b} T diphtheria." Carnevall and M. Aurelius Severinus, as 
well as Franciscus Nola and most other writers of the 17th 
century, admit the contagious nature of diphtheria. 

Dr. Samuel Bard, speaking of suffocative angina, sa3~s, 
"The disease I have described appeared to me to be of an 
infectious nature, and as all infection must be owing to 
something received into the body, this, therefore, whatever it 
is, being drawn in by the breath of a healthy child, irritates 
the glands of the fauces and trachea as it passes b} T them, 
and brings about a change in their secretions. The infection, 



MODE OF PROPAGATION. 35 

however, did not seem, in the present case, to depend so 
much on any generally prevailing disposition of the air, as 
upon emu via received from the breath of infected persons. 
This will account why the disorder should go through a 
whole family and not affect the next door neighbor." 

The views of more recent writers on this question may be 
gleaned from the following extracts from their writings. 

Dr. Rankin says, " My own conviction is that it is infec- 
tious to a limited degree, by which I mean that when patients 
are accumulated in small, ill-ventilated rooms, the disease is 
like!} 7 to be communicated, but I do not fear that, like scar- 
latina or erysipelas, it may be propagated in spite of sanitary 
precautions still less that the infection may be conve} T ed by 
the clothes of those who visit or superintend the patients." 

" Out of forty-seven families infected," saj^s Dr. Ballard, 
"there were only fifteen in which the other members all 

remained healthy. As a rule, it spread in the houses 

it invaded chiefly among those members who were most 
closely in communication. In no case where separation from 
the sick person has been effected early in the disease, have I 

noticed that it has spread to the separated individual. 

Jane J., aged ten years, resided at Islington, with her 
mother, an aunt, and three sisters. On May 1st and 2d 
she was on a visit at the house of an uncle, whose daughter, 
Jane's cousin, was kept at home, because she was believed to 
have a cold. On the 2d, this child exhibited decided 
symptoms of diphtheria ; the attack was slight, and she 
recovered. On Ma}- 6th, a servant in this house was taken 
ill with a severe attack of diphtheria and was removed to St. 
Bartholomew's Hospital, where she died. On the 2d Jane 
returned home, was taken ill on the 3d with diphtheria in a 
severe form, and died an Ma} 7 9th. Her mother and a 
sister, aged fourteen 3 T ears, were both taken ill on May 11th. 
She had not been so much with her daughter as other 
members of the family up to the 8th, when she sat up with 



36 DIPHTHERIA. 

her all night. The tonsil sloughed, and there was a complete 
cast of the trachea expectorated. She died on the 18th. The 
sister, who was also attacked on the 11th, slept with her 
mother, and when not at school, was continually in and out 
of Jane's room, sitting there sometimes for hours together. 
She died on May 14th, asphyxiated. Another sister who 
slept with Jane and the aunt, suffered from nothing but a 
slight sore throat." 

M. Daviot and Dr. Moncton, (London, 1857), regard diphthe- 
ria as purely and simply an epidemic disease, and not contagious. 

Dr. Jenner comes to the following conclusions: — -"First, 
that the disease is infectious ; second, that the infecting ele- 
ment does not require for its development any of the ordina- 
rily considered antihygienic conditions ; third, that the family 
constitution is one of the most important elements favoring 
the development of the disease and determining its progress ; 
fourth, that it is very doubtful even if any of these hygienic 
conditions favor its development, or give it a more untoward 
course when it occurs." 

Dr. Mackenzie (1879) gives it as his opinion that "The dis- 
ease may be imparted to others by a person actually or lately 
suffering from it, but the extreme difficulty of effecting arti- 
ficial implantation would tend to show that direct contagion 
is rare. From this fact it would seem probable that the con- 
tagium, when set free from the affected individual, undergoes 
further development, which increases its disease-producing 
properties." 

In proof that the contagion may be convej'ed by a person 
not actually affected by the disease, Dr. Mackenzie quotes the 
following very remarkable case reported by Dr. Thursfield : 

" A woman living in an infected house, but not at any 
time suffering herself, walked a mile or two and crossed a 
ferry to visit a friend. She only remained a short time in the 
house, but sufficiently long to leave the germs cf diphtheria, 
which broke out a day or two afterwards." 



MODE OF PROPAGATION. 37 

Again he says, " I have known the disease caught from a 
patient, who had entirely recovered from it four months pre- 
viously ; but whether it was conveyed by the person or 
clothes of the individual, it was impossible to determine." 

The distance at which the. contagion can act through the 
medium of the atmosphere appears more limited than is the 
case in typhus or small pox. Thus in my own practice, two 
families resided in the same house, in one of which were 
three, and in the other four children. In the former all the 
children were affected with the disease, and one died ; in the 
latter, although the children were continually about the yard 
and house, though not admitted to the apartments of the 
sick, all escaped infection. 

Mackenzie ssljs, " I have known an instance in which 
seven children were affected in a house, which had a residence 
on each side of it, and a third opposite, at a distance only 
twenty-five feet. Although in all of these buildings were 
young children, no other case of diphtheria occurred." Many 
similar illustrations might be given. It would seem, how- 
ever, that in certain conditions the diffusive powers are in- 
creased, and the poison wafted over extensive tracts of coun- 
try. 

It is seen by the foregoing that the poison may enter the 
system, a. Possibly by direct contact. 

b. Through the circumambient air ; (see remark 2.) 

c. With the water that is drunk, or the food that is eaten. 
This last proposition, though apparently self-evident, I 

regard as most difficult of satisfacto^ proof. During the 
prevalence of epidemic disease people are more guarded in 
this than most other respects. The following cases, some- 
what to the point, are taken from Prof. M. Mackenzie's late 
work. A greyhound was seized with symptoms akin to diph- 
theria four days after swallowing the excrements of a child, 
who died of that disease ; after death, a membraneous exuda- 
tion was found upon the animal's fauces. 



38 DIPHTHERIA. 

Three sows which had access to a piece of waste ground, 
on which the discharges or excretions of some patients suf- 
fering with diphtheria, were thrown, quickly died with symp- 
toms of suffocation, enlarged sub-maxilla^ glands, and, in 
one case, with diphtheritic membrane in the fauces. 

These instances go to prove the possibility of systemic 
infection by means of the ingestion of morbific matter. 



REMARKS. 

1. The infectious matter contained in the secretions may 
not only be exhaled into the air, and thus by inhalation, or 
absorption through the cutaneous surfaces, be the means of 
infection ; it may likewise find its w T ay into privy vaults and 
thence to neighboring wells, contaminating the water, making 
it infectious ; or into sewers from w 7 hich through defective 
traps it may be exhaled into dwellings at even remote dis- 
tances : or through catch-basins it may infect children pla} T - 
ing in the immediate vicinity. 

2. Inoculation with diphtheritic false membrane,by Trous- 
seau, Peter, and Duchamp, upon themselves, and by Harley 
upon animals produced either no effects or only such as 
relate to common purulent infection. As practiced upon 
rabbits by Trendelenburg and Oertel, it produced diphtheritic 
membrane in the trachea, general infection, and death the 
third day. 

Nassiloff and Eberth, Heuter and Oertel, succeeded in 
inducing membranous exudations upon the cornea, upon the 
edges of wounds, and death of the animals on the second 
da} r from septicaemia, which may have resulted from the 
inoculation with decomposing animal matter. It is not, 
therefore, rendered certain b}" these or any other experiments 



PREDISPOSING CAUSES. 39 

with which the author is acquainted, that true diphtheria has 
yet been induced by the process of inoculation. 

Further critical observations seem necessary to settle this 
point, 



CHAPTER VII. 
PREDISPOSING CAUSES. 

Age. In Great Britain the Registrar General's returns 
give an analysis of about 70,000 fatal cases. In each thou- 
sand the age at death is shown in the table below : 

Age. No. 

Under 1 year 90 

From 1 to 5 years 450 

" 5 !: 10 l " , 260 

'• 10 " 15 " 90 

" 15 c - 25 " 50 

" 25 < : 45 " 35 

45 and upwards 25 

1,000 

In the epidemic of Florence, in the } T ears 1S71 and 1872, 
out of a total number of cases of 1546, only fifteen were over 
thirt} T 3'ears of age. 

It will thus be seen that diphtheria is peculiarly a disease 
of childhood, the vast majority of cases occurring between 
the ages of one and ten years. Infants at the breast gener- 
ally escape, and the younger the child the less liable it is to 
contract the disease. 

In the table above given, we notice that the liability during 
the first year is (judging from the fatalit}-) just equal to that 
of the aggregate of the five years between ten and fifteen. 
If then it be proper to say, as above, that " infants at the 
breast generally escape," so it may be said that those above 



40 DIPHTHERIA. 

ten years of age generally escape, and the greater the age 
past fifteen the greater the exemption. 

Sex seems to exercise no appreciable influence upon the 
susceptibilit}' to diphtheria. 

Constitutional predisposition varies greatry in different fam- 
ilies, and is no doubt greatly influenced by modes of living 
and sanitary surroundings. The author is able to recall a 
number of instances illustrating this statement. The family 
of H., residing at No. — Columbus St., Cleveland, Ohio, with 
"no particular constitutional taint except that induced by the 
intemperance of the father, gross and unhealthy- food, and 
filthy habits, were attacked in the Summer of 1874, and two 
of three cases were quickly fatal, while all the other families 
in the same neighborhood, of better habits and consequently 
better constitutional health, and with an equal or grearter 
number of cases, at first, at least, of apparently equal malig- 
nity, and having the same medical care, recovered without 
loss, except in a single instance with similar surroundings to 
the first. 

Sir Wm. Jenner lays great stress upon " family constitu- 
tion " as being " one of the most important elements favor- 
ing the development of the disease and determining its pro- 
gress." 

In one of his families five members took the disease, in 
two others, four each, and in eight, two each. In the Lancet, 
vol. I., p. 919, are reported two examples ; in one family 
eight, and in the other six cases were fatal within a few 
days. Few active practitioners of the present day in our 
cities but have noticed similar cases. I have known several 
such in our own city, — cases in which every child in families 
numbering from one to five, have been suddenly removed. 

I have been wont to attribute these results to constitu- 
tional predisposition ; meaning dyscrasia and the result of 
evil habits, which I think more expressive of the facts than 
"family susceptibility" employed by Jenner and others. 



PREDISPOSING CAUSES. 41 

Mackenzie gives the following. A poor woman had three 
children of her own, and took care of two others in no way 
related to herself ; her own children were attacked by the dis- 
ease and one of them died. The two other children not her 
own, who were constantly in the same rooms with the pa- 
tients, never suffered from the disease. 

Four families occupied the same house, and each had sev- 
eral children. In two the mothers were sisters, but not re- 
lated to the others. All the children related to each other 
had diphtheria severely whilst the children of the other two 
families escaped entirely, although no attempts at isolation 
were made, the healthy children often entering the rooms of 
the patients. 

Neither rank, station nor occupation seem materially to 
influence the liability to the disease. Its visitations are regard- 
less of modern improvements in human habitations, of the 
ease and luxury of the rich, the exaltation of rank, as in the 
family of the first Napoleon, the present royal house of Eng- 
land, and as some claim, the revered Washington. Dr. Green- 
how remarks, " Station of life and the enjoyment of affluence, 
or exposure to the privations of poverty, seem to have but 
small influence either in predisposing persons to take or to 
suffer severely from the disease." 

Prof. M. Mackenzie says, " It must not be forgotten, more- 
over, that when diphtheria becomes epidemic in a town, an 
elaborate system of drainage is calculated to convey the 
poison by means of the sewers, and that water closets afford 
a ready means of contaminating cisterns and introducing 
sewer gas into residences. Hence the wealthy are some- 
times subjected to the causes of infection, which the poorest 
may escape." 

Although the 'prevalence of diphtheria may not be material- 
ly affected by sanitary conditions, no medical man will doubt 
that its fatality is. Every one knows that good medical care, 
good nursing, and good sanitary surroundings, are prime 



42 DIPHTHERIA. 

factors each in the restoration of the sick, and not less, so in 
diphtheria than in typhoid or scarlatina. 

Among the affections predisposing to the disease we must 
not omit catarrh of the air passages. We have before shown 
the increased liability to diphtheria in inflamed and irritated 
states of the mucous and cutaneous surfaces ; hence also 
scrofulous inflammation and other glandular enlargements 
and diseases of the skin may properly be ranked with the 
predisponents. 

Measles and scarlatina stand prominent among the predis- 
posing causes, and when they are succeeded by the disease it 
is commonly denominated " Secondary Diphtheria." 

It is the opinion of writers that the predisposition to diph- 
theria is lessened by previous attacks of the disease. The 
immunity thus conferred must be veiy trifling, as it is no un- 
common occurrence for persons to have the disease a second 
and a third time. I have seen in my own practice several 
such cases, well characterized, and one in my own family of 
great severity and danger with large membranous patches in 
the fourth attack. Dr. Mackenzie says, "I have myself 
known three instances in which children have died from the 
second attack." In another case a patient had diphtheria in 
Ma}', and again in a fatal form in the July following. Still, 
it is not necessary to dissent entirely from the idea of partial 
immunity resulting from antecedent attacks. 



CHAPTER VIII. 
PERIOD OF INCUBATION. 

This may and probably does vary according to different 
degrees of susceptibility, and the greater or less dilution of 
the contagium. According to m} T observation of cases, I 



PERIOD OF INCUBATION. 43- 

should say it ranged from a single day or less (rarely), to 
fourteen or fifteen days. 

Prof. J. Lewis Smith, of New York, reports the following 
on this point : "A boy of nine 3-ears was in the same room 
about one hour on Saturday with a child w r ho had fatal diph- 
theria. On the following Tuesday, without any other ex- 
posure, he sickened with a malignant form of the same dis- 
ease. Mrs. E. assisted in nursing a fatal case of diphtheria 
from Nov. 11th to 13th, 1874, after which she returned home r 
several blocks away. On the evening of the 1 5th she complain- 
ed of sore throat, and on the following daj T the diphtheritic 
pseudo-membrane was observed over her tonsils. On the 
19th the exudation had disappeared, and she was convalescent. 
On the 20th her sister residing with her, and who had not 
been elsewhere exposed, was similarly affected, and after 
three or four days also convalesced. The only other case in 
the family, a boy, sickened with diphtheria on Dec. 2nd." He 
pronounces the period of incubation to be from two to eight 
da3 T s, with perhaps an occasional case outside of these limits. 

Prof. Mackenzie w T rites, U A girl, aged six, w r ho had been 
absent from home five weeks, returned one afternoon at four 
o'clock. Her young brother, aged four, had shown symptoms 
of sore-throat the same morning, but no suspicion was enter- 
tained that the disease was diphtheritic. These two children 
remained together till bedtime, but did not sleep in the same 
room. The next morning both of them had marked diph- 
theria, with an abundance of false membrane. The little 
girl had not been subjected to any infection before reaching 
her home." The extremes seem to be a few hours and fifteen 
da} T s. These deductions are in accord with most other 
authorities, and are entitled to great confidence. 



44 DIPHTHERIA. 

CHAPTER IX. 
PROPHYLAXIS. 

" Patients affected with the disease should be isolated as 
far as practicable. Vessels receiving the excretions should 
be disinfected. Everything coming in contact with the 
patients should be disinfected or destroyed, and disinfection 
should be added to thorough cleaning of the rooms and 
furniture after cases have terminated." (Flint.) 

The foregoing is an epitome of the teachings of the best 
authorities both in America and Europe. Isolation may 
be effected by the removal of the patient or the other mem- 
bers of the household to separate apartments as far apart as 
practicable, and prohibiting all intercourse. Disinfection of 
the vessels receiving the excrements may be effected by 
keeping in them a small quantity of dry calc. chlor., a ten 
percent solution of acid, carbol., or an eight percent solution 
of choral, hyd., &c, with frequent scalding with hot water 
after use. These measures are also useful for disinfecting the 
atmosphere of the apartments, which may also be promoted 
by hanging sheets or blankets, wet with similar solutions in 
the windows or doorways of the sick room. The clothing of 
patients and cloths used around them are disinfected by im- 
mersing them in hot solutions of calc. chlor., of about the 
strength of 3 i to cong. i. 

All carpets and unnecessary furniture and hangings as 
well as needless clothing should at once be removed from 
the apartments of the sick. After recover}" the room, 
tightly closed and containing all its furniture of every kind 
not otherwise purified, should be disinfected by the fumes of 
burning sulphur, in the following manner : Dip cotton or 
linen cloths of considerable size in melted sulphur, and put 
one or more of these in an open iron vessel so placed in the 
apartment, as not to endanger it by too great heat, and 



SYMPTOMS. 45 

ignite. Having thus filled the room with a dense volume of 
the smoke, leave it closed two or three hours, when, after 
thorough ventilation, disinfection may be considered per- 
fected, and the apartment fit for occupation. 

The author's views on medical prophylaxis are given inci- 
dentally in the subsequent parts of this work, and at the close 
of chapter XXI, and they are regarded as of prime impor- 
tance on account of the efficiency of the measures recom- 
mended. 



CHAPTER X. 
SYMPTOMS. 

"We will next describe a typical case of diphtheria as it is 
generally seen in this countiy, with the most common com- 
plications, in the order of their occurrence. In order to 
facilitate the description and aid in the investigation, I have 
divided the disease into three periods or stages, all neces- 
sarily varying in degree and duration. The first or initial 
stage extends only to the formation of a distinct false 
membrane, the only real diagnostic of true diphtheria. The 
second period or stage begins with the close of the first, and 
extends to the disappearance of the false membrane. The 
third period embraces the entire period from the close of the 
second to complete recovery. 

First stage. This stage is characterized by languor, the 
patient evincing little relish for amusements ; the appetite is 
impaired, there being sometimes complete anorexia with 
vomiting, which in this early stage is indicative of consider- 
able severity as the disease shall develop. Diarrhoea at this 
period is occasional but not common, and if slight, may be 
regarded as salutary ; but if severe and accompanied by other 
violent symptoms, indicates a grave form of. the disease. 



46 DIPHTHERIA. 

" The s} T niptouis of invasion have less prognostic value in 
diphtheria than in most other infectious maladies. We meet 
cases with a severe beginning, attended by delirium, which 
terminate in apparently complete restoration to health in less 
than a week, the presence of the characteristic pellicle on 
the fauces, and the occurrence of diphtheria in other mem- 
bers of the family rendering diagnosis certain. On the 
other hand, a mild commencement sometimes ushers in a 
fatal form of the disease. This is notably true of these 
cases in which hiiyngitis supervenes, as it not infrequently 
does in cases which begin very mildly." (Smith.) 

If inquired of, the patient will probably complain of head- 
ache, and a sense of fullness or slight soreness of the throat. 
The neck feels stiff, swollen, and tender, and deglutition is 
slightly painful. Examination will be likely to reveal redness 
and congestion of the faucial surfaces. The tonsils will 
appear somewhat swollen, and coated with tenacious mucus. 
Occasionally specks of yellowish or whitish exudation 
scared}' distinguishable from thickened mucus, translucent, 
and appearing slightly elevated, will be observed upon the 
tonsils, uvula, or other parts of the faucial surfaces. These 
are to be regarded as the elementary exudation, or false 
membrane, characteristic of diphtheria. 

Severe chills are rare ; the patients, however, generally 
complain of chilly sensations, and instinctively avoid 
exposure to cold. This state is quickly followed, or it may 
even be accompanied by increase of temperature, proximately 
100° to 105°. If the patient is an adult, he often complains 
of giddiness, and pain in the loins. 

The tongue is moist and clean, or slightly coated. The 
pulse will generally be found soft, and onty slightly if at all 
accelerated. The patient may still continue to walk about 
and regard his ailment very trifling, notwithstanding the 
physician may regard it with considerable anxiety. 

In malignant cases the attack often begins with severe 



SYMPTOMS. 47 

rigors, and in addition to headache and vomiting there may 
be haemorrhage from the nose, and the patient is greatly 
prostrated by the virulence of the attack. The throat 
symptoms may not be more severe, but the secretions 
undergo rapid decomposition and impart to the breath an 
intolerable fetor. The pulse is small, rapid, and irregular; 
the temperature is not high and may even be less than 
normal. The patient, restless at first, soon becomes apathetic 
and drowsy; face pale; skin cold and clammy, and of an 
ashy color; the tongue dry, tremulous, and of a brown or 
blackish color, and sordes already begin to accumulate on 
the teeth. Haemorrhages sometimes occur from the throat 
or nasal passages or other mucus surfaces, and petechias 
often appear beneath the skin. In such cases the patient 
loses consciousness or becomes delirious, and may die even 
in this early stage in a state of coma, or from an attack of 
syncope. 

This period, sometimes inappreciably brief, may continue 
one or two days, and is terminated by the appearance of the 
distinct false membrane which characterizes the beginning 
of the second stage. 

It must not, however, be inferred that cases, stages, or 
symptoms, are so uniform that all the conditions of any two 
cases will be found identical. They vary widely, but are 
recognizable by the experienced plrysician by common char- 
acteristics which cannot be fully defined. 

Second stage. The patient has generally by the beginning 
of this period taken to bed, and appears really sick. The 
eyes seem a little suffused, the cheeks red or dusky. The 
voice sounds thick although respiration is unimpeded. 
P}Texial indications are more pronounced. Complaint is 
made of painful deglutition ; the parotid and submaxillary 
glands and the lymphatics of the front and sides of the 
neck are some or all of them swollen and tender. When 
this swelling is limited to the parotids, the appearances are 



48 DIPHTHERIA. 

often suggestive of mumps, for which the disease has been 
mistaken. The neck often appears large and brawny, there 
being superadded to the glandular infiltration no inconsider- 
able degree of cellulitis. The cells are filled to a greater or 
less degree with solid material, in its composition doubtless 
analagous to the exudation that occurs where the epidermis 
is removed. 

This state of the structures of the neck may continue or 
even increase during this entire period. Occasionally sup- 
puration occurs, especially in cases following scarlatina. In 
cases of unusual debilit} T , this condition must be considered 
critical. Preventive means should be employed. 

The skin in most cases feels hot and dry, in others it is 
moist. The pulse is generally accelerated and may number 
90, 100, or even 120 or more, and is soft. In those cases 
tending to malignit}-, as before stated, it is greatly acceler- 
ated, small, and irregular. Exceptionally, too, at this 
period, the pulse rate is found extremely low, counting only 
from 30 to 60. This is to be accounted for by the effects of 
excessive toxaemia upon the brain and nervous system. 
During the early part of this stage the temperature in most 
cases is high, often reaching from 104° to 105° or even 
higher, but during the first few days, in most instances, 
gradually subsides as the exudation extends. In a few 
cases it remains high, and may even increase during the 
period of exudation. M. Farralli, of Florence, states that 
it usually falls to the normal by the fourth or fifth day, 
though in moderately severe cases it shows a tendency to 
rise after that date. 

" The fever which ushers in diphtheria, abates after the 
second or third day, and subsequently, in grave as well as 
in benign cases, there may be little or even no elevation of 
temperature. The diphtheritic poison does not, therefore, 
like that of scarlet fever, exhibit any marked tendency to 
increase the animal heat. Even in profound and fatal blood 



SYMPTOMS. 49 

poisoning in this disease, the thermometer shows the normal, 
or scarcely more than normal, temperature, so that the inex- 
perienced practitioner is apt to be deceived in his prognosis. 
On the other hand, a continued elevation of temperature 
with only moderate angina should lead the physician to 
examine for some complication, perhaps a nephritis." (Smith.) 

The asthenic character of the disease as well as the prim- 
ary blood poisoning is not only exhibited by the temperature 
and character of the pulse, but by the appearances of debility, 
which the patient exhibits, and by the albuminuria, which is 
at this stage a common symptom. The urine is high 'colored 
and scanty, and, as in other febrile diseases, is found to con- 
tain an excess of urea as well as albumen, with hyaline, 
granular, and epithelial casts. As might be expected, the 
patient is thirsty, though often refraining from drinking on 
account of pain in swallowing. The appetite is variable, gen- 
erally poor, and vomiting not rare, which, with the painful 
deglutition, often renders nutrition difficult. Vomiting is, in 
my opinion, generally to be attributed to the influence of the 
primary morbid poison on the nervous system, being in some 
sense a measure of the toxaemia. Smith regards it as fre- 
quently the result of uraemia. The strong analog} 7, of this 
effect of diphtheritic poison to other well known systemic 
poisons, for which antidotes have been discovered, is a sug- 
gestion of some weight in favor of the antidotal treatment 
of this malady, which will be brought forward in a subse- 
quent part of this treatise. 

The bowels may be constipated, relaxed, or normal. 

The mind, except in malignant cases, generally remains 
clear throughout the disease. More or less delirium, how- 
ever, is often met with, and is to be interpreted in connection 
with the other symptoms. 

The tongue in the earl}- part of this stage is generally 
moist and slightly coated. The coating is generally yellowish 
or grayish; if dark colored and dry generally indicates a 
4 



50 DIPHTHERIA. 

typhoid state, and is one of the indications for stimulating 
treatment. 

The tonsils are more swollen than in the first stage, and 
the secretion covering them more dense, yellow, and viscid. 
This condition occasions often repeated efforts by hawking 
and spitting to clear away the annoying secretion. Even the 
hawking ma} r indicate varied degrees of violence. Upon the 
surface of the tonsil or in other parts of the pharynx will now 
be observed the characteristic patches of exudation, of a yel- 
lowish or whitish color, elevated above the surrounding 
mucous surface, and, in proportion to their development, 
presenting a more dense and leathery or felted appearance. 
These render the diagnosis positive. If they be forcibly 
detached, their intimate connection with the submucous tissue 
will be rendered apparent. More or less haemorrhage follows 
their separation, which with the fibrils projecting from their 
under surface shows their connection with the capillaries 
beneath, and evinces the derivation of the membrane from 
the blood by exudation. If abundant, therefore, it shows 
violent toxaemia, and the future developments will probably 
be proportionate in severity. They further indicate by their 
fibrinous structure such a condition of blood as leads to 
coagulation of its fibrin. This state is further evinced by 
the frequent occurrence of fibrinous clots in the heart, and in 
the course of the circulation. As the disease progresses, 
these patches tend to extend their area and coalesce, some- 
times forming a continuous coating over most of the pharyn- 
geal surfaces. Their thickness is at first constantly increased 
by continued exudation upon their lower surfaces, and hence 
their elevated appearance. If, however, the contiguous 
mucous surfaces be so swollen as to be even with or elevated 
above the edges of the membrane, it appears depressed. 

By extension and coalescence these membranes sometimes 
reach the epiglottis and ary-epiglottic folds, or the larj^nx, 
and even the lower air-passages, constituting diphtheritic 



SYMPTOMS. 51 

croup. This form of disease is characterized by most of the 
S3 T mptoms of pseudo-membraneous laryngitis, or true croup, 
with which it was considered identical by Brettonneau, and 
since his time by many French and English authors. The 
most recent and able advocate of their identity is Prof. 
Morell Mackenzie, M. D., of London. We are obliged, how- 
ever, after a careful consideration of facts, to dissent from 
this view, which will receive further consideration hereafter. 

The voice in this condition at first becomes husky, high- 
pitched, and is at length extinguished. The cough becomes 
hoarse, shrill, barking, stridulous, and finally entirely aspirate 
or voiceless. This is often called the croupy cough, and 
never fails of recognition after being once heard. The 
breathing becomes labored, stridulous, and insufficient for the 
regeneration of the blood, hence the countenance becomes 
suffused, swollen, purple, and the ej^es seem to protrude 
from their sockets. 

If the chest be examined, both the inspiratory and expi- 
ratory sounds will be found prolonged, and the bronchial 
and vesicular murmurs obscured or rendered inaudible by 
the larjmgeal stridor. The intercostal and supraclavicular 
spaces are more depressed during inspiration than during 
healthy breathing, and more prominent during expiration. 
The dyspnoea continues to increase and the patient suffers 
from repeated attacks of suffocation. When these attacks 
occur, the little sufferer springs up in bed, the face is gorged, 
and livid, the expression terrified and indescribably anxious. 
The nostrils are rapidly expanded and contracted, breathing 
is nearly impossible by even the greatest effort, and the 
hand is often thrust into the mouth or clutches the throat in 
a vain effort to remove the obstruction. After a few min- 
utes the paroxysm subsides, and a period of comparative 
repose, sometimes of several hours' duration, ensues. The 
Continuous cough and sense of a foreign body in the throat 
leads to paroxysms of vomiting, during which patches of false 



52 DIPHTHERIA. 

membrane, varying in size, are often ejected with consider- 
able relief to the sufferer. Death, however, from closure of 
the glottis by the exudation or by oedema has been the usual 
result, which is only occasionally prevented by energetic timely 
treatment. Such is laryngeal diphtheria or diphtheritic croup. 

If, on the other hand, the membranous extension be to the 
nares, or if they constituted its original seat, the case is de- 
nominated nasal diphtheria. 

" In some epidemics of diphtheria the disease commences 
with nasal catarrh, and this phenomenon was so common in 
the epidemics witnessed by Bretonneau that he regarded it as 
the ordinary course of the disease. Further experience, how- 
ever, has demonstrated that catarrh of the nose is far less 
usual than was at one time supposed, and that true nasal 
diphtheria is generally due to the extension of the plastic 
inflammation from the pharynx. The disease commonly first 
shows its appearance by an unhealthy brown ichorous dis- 
charge, which causes abrasion, and even ulceration of the 
skin in the neighborhood of the nostrils. Soon afterward the 
parts are covered with false membrane, which can be seen 
extending through, the nose. At other times the false mem- 
branes do not reach the external orifice, but, on using the 
speculum, a few scattered deposits of lymph can be discover- 
ed on the mucous membrane of the septum or turbinated 
bones. The false membrane, however, is generally most 
abundant at the posterior nasal orifices " (Mackenzie.) Dur- 
ing the progress of nasal diphtheria epistaxis often occurs. 

The lachrymal duct is. occasionally the seat of diphtheritic 
inflammation and exudation, causing by closure of the puncta 
an overflow of tears. Following this route it occasionally ex- 
tends to the conjunctiva. 

If it follow the tract of the eustachian tube it occasions 
complaint of noises and darting pains in the ears, and deaf- 
ness, followed, perhaps, by perforation of the membrana 
t3 7 mpani and purulent discharge from the ears. 



SYMPTOMS. 53 

When the false membranes begin to decay or separate, the 
breath sometimes becomes fetid and very offensive. The 
fetor is often erroneously regarded as that of gangrene. The 
products of the decay of these membranes, if neglected, may 
lead to true local gangrene of the diseased and debilitated 
structures of the throat. They may also by absorption into 
the circulation produce pyaemia with its troublesome or fatal 
consequences. These may all be prevented by the timely 
use of appropriate antiseptic medication. 

If a patient suffering from diphtheria in this stage has any 
portion of the body denuded of its covering of cuticle, as 
from blisters, open sores, or surgical injuries, these parts 
often become coated with the exudation, sometimes forming 
troublesome ulcers, occasionally, perhaps, fatal. Two chil- 
dren in the same family living in L. st., Cleveland, were at- 
tacked upon the same day with diphtheria. When first seen 
the boy had large patches in the throat, much glandular en- 
largement, and upon a sore on his left ankle, a diphtheritic 
membrane well formed. The foot was hot, swollen, and ex- 
quisitely tender. The girl, beside severe diphtheria in its 
usual locality, had marked manifestation of the disease upon 
two sores upon the dorsum of the left foot. The limb, as 
far as the knee, was greatly swollen and of an erysipelatous 
color. The sores were foul at the edges, with a distinct mem- 
brane covering the centre, and depressed below the level of the 
surrounding swollen integument. The constitutional dis. 
turbance was very great. Under appropriate treatment both 
cases terminated favorably in about ten daj-s. 

The other mucous openings, as the rectum, vagina, and 
urethra, are likewise the occasional seats of violent diph- 
theritic disease. I have known a female patient, otherwise 
apparently likely to recover, destroyed by vaginal diph- 
theria. 

Occasionally also quite severe diphtheritic inflammation 
with patches of exudation may be observed on the buccal 



54 DIPHTHERIA. 

and gingival mucous surfaces ; upon the lips, and upon or 
beneath the tongue. 

So great, indeed, is the dyscrasia that wherever in the nat- 
ure of the case it is possible, there occurs this exudation of 
the fibrinous elements of the blood, depriving the circulating 
fluid, in a measure, of its nutritive properties. It is during 
this second stage of diphtheria that gangrenous s}'inptoms 
occur, constituting gangrenous diphtheria. As before remark- 
ed, this state may result from the irritating and poisonous 
effects of the matter of decomposition of the false membrane, 
upon the inflamed and weakened contiguous structures. It 
may likewise result from constitutional peculiarity or debility, 
but most frequently occurs in cases supervening upon scarla- 
tina. " The gangrene frequently supervenes with great rapid- 
it}' after the formation of the false membrane, so that in two 
or three da}'s a large portion of the pha^ngeal mucous mem- 
brane may be sphacelated. In some cases there is consider- 
able swelling of the cervical glands, but this lesion is not 
invariably present. As the morbid process becomes fully 
developed, it is, in all instances, accompanied bj* a remarkable 
prostration of the vital powers. A state of collapse com- 
parable to that which occurs in cholera, indicates the inten- 
sity of the blood-poisoning ; there is great loss of bod}'-heat, 
and the pulse soon becomes slow and infrequent. The ex- 
tremely feeble condition of the circulation is shown by the 
pallor, coldness, and bluish discoloration of the skin, especially 
of the extremities and prolabia. The expression of the face 
is strikingly altered and pinched. The patient generally dies 
from sjmcope, the intelligence often remaining intact to the 
last. In some cases, however, he becomes comotose, and 
occasionally S}~mptoms indicative of profound lesions of the 
thoracic or abdominal viscera are manifested. These cases 
always terminate fatally." (Mackenzie.) It is by no means 
rare during the second stage for haemorrhages from the pha- 
ryngeal or nasal surfaces to occur, either as a consequence 



SYMPTOMS. 55 

simpty of the intense local congestion or the detachment of 
the false membranes. 

This ought, perhaps, to be attributed as much to the 
disorganized state of the blood as to vascular engorgement, 
which is not sensibly lessened by the loss. The effects of 
haemorrhage, be it never so slight, in a disease so generally 
characterized by debility, is to be deprecated, as by increasing 
the debility it decreases the chances of recovery. It should 
be prevented or arrested when possible. 

Skin eruptions occasionally occur during this stage, and in 
some epidemics are common among children, and generally 
consist of a rash upon the neck and chest resembling that of 
scarlatina. It sometimes appears upon the face, abdomen, 
and thighs. Neither the date of its appearance nor its 
duration are at all uniform. In a few cases it persists for 
several da}~s ; in others but a few hours ; and it is seldom or 
never followed by desquamation, like that of scarlatina. It 
usualty disappears before the close of this period. 

The catarrhal state, mentioned among the predisposing 
causes, may, during this stage, occasion cough from bron- 
chial or pulmonary irritation. Any catarrh, whether recent 
or otherwise, is mainly pernicious as tending to change the 
more common forms of the disease to nasal or larjmgeal 
diphtheria, therefore any exposure to its causes should be 
studiously avoided. 

The duration of this stage is exceedingly various. In the 
mildest forms of the disease it can hardly be said to exist, 
there being very little exudation, or none at all, and but 
trifling indisposition. In more violent typical cases it may 
extend through a period of five to fourteen days. 

The fever of diphtheria has certain peculiarities entitling 
it to still further consideration. Like the fever of small pox 
it is, in tj^pical cases, divided into two periods, which may 
be denominated primary and secondar} 7 , and it follows a 
tolerably regular course. The primary fever, as before 



56 DIPHTHERIA. 

mentioned, comes on rapidly, and even in cases of only 
moderate severity the temperature frequently rises as high 
as 103° to 105° F. Within twenty-four hours it begins to 
decline, and by the end of the third or fourth day the tem- 
perature becomes nearly normal. This fever is the result 
of the diphtheritic blood poisoning. 

In cases of only moderate violence the temperature begins 
again to rise on the fourth or fifth day, and is found to be in 
proportion to the other symptoms of septicaemia, notably the 
glandular swelling, which is often attended b} T renewed 
exudation. As in small pox, so in all probabilit}^ this secon- 
dary fever results from the absorption of septic matter at the 
points of local disease. The effects of this secondary infection 
are more manifest in severe cases which exhibit a typhoid 
type. In these it rises less regularty, and in degree it is in 
proportion to the amount of local disease and putrefactive 
changes. In the more favorable cases the normal temperature 
is again reached in a few days, whilst in very severe cases it 
may continue to rise until a fatal termination ensues. Com* 
plications ma} T interrupt the natural course of this secondary 
fever ; if of an inflammatory nature they may increase the 
temperature ; if malignant or tending to obstruct respiration, 
the temperature will be reduced. The course ©f the fever has 
been the same where the local manifestation of the disease 
was limited to a wound, as when upon the pharynx or 
larynx. 

M. Labadie Lagrave gives the following as the results of 
carefully conducted thermometric observations in fift} T -five 
cases : 

11 1st. The temperature generally rises to 104° on the first 
day, and remains at about that point for two or three da) T s, 
without any marked morning or evening remissions. 2nd. 
It begins to fall on the third or fourth day of the disease, 
and then invariably continues to fluctuate between 99.5° and 
101.5° unless some complication develops. 3d. Tracheotomy 



SYMPTOMS. 57 

exerts no marked influence on the temperature. 4th. In 
favorable cases after the initial pyrexia has subsided, the 
temperature never rises above 102°. A sudden ascent to 
103° or 104° on the fifth or sixth day of the disease points to 
the development of some complication ; either acute neph- 
ritis, lobular pneumonia, or acute eudocarditis." 

Either continued high temperature or a sudden rise after 
the fourth day should, therefore, lead to careful, search for 
these complications, but may be occasioned by the absorption 
of morbific matter as before stated. 

A few remarks on the manner of the separation of the false 
membrane will conclude the consideration of the second 
period. Some forms of treatment cause its apparent dis- 
integration by either local or constitutional effects, or both 
■combined, but reference here is only had to the pathological 
processes by which separation is effected, independent of the 
effects of medicinal agents. Prof. Rindfleisch of Bonn says 
of the false membrane, " It is a whitishgray, compact, felted 
membrane, which is elevated, perhaps to the height of one- 
half line above the level of the mucous membrane, and 
penetrates just as deep into the substance of the mucous 
membrane, and is most intimately connected with the latter." 
A sharply defined boundary line separates the living tissue 
from the dead, as we can convince ourselves with the naked 
eye, but numerous connective tissue fibres, blood-vessels, 
nerves, and elastic fibres, pass over from the dead ; they must 
all have separated ere the loosening can proceed. The means 
which are placed at the command of the organism are inflam- 
mation and suppuration. We call this inflammation reactive, 
and unite with it the idea as though this were an answer to the 
irritation which the diphtheritic scab exerts upon the sur- 
rounding mucous membrane ; yet a portion of the hyperemia 
also may be explained according to static principles, as col- 
lateral fluxion. The pus collects between the scab and the 
healthy parts, and always, accordingly as the fibrous bridges 



58 DIPHTHERIA. 

mentioned melt down and tear, the separation begins now at 
the edges, then at the centre. After it is completed an ulcer 
remains behind which is disposed to rapid cicatrization ; not 
unfrequently, however, the process repeats itself again at the 
same place ; we have a new scab, and with it anew the 
necessity of a purulent separation, after whose termination a 
ver}' considerable loss of substance remains. The cicatrices 
finally resulting distinguish themselves by their capacity of 
vigorous retraction, so that the danger of subsequent con- 
traction of mucous membrane canals, especially of the large 
intestine after d} T sentery, threatens so much the more, the 
more diffused the ulceration was." 

During this process, there is no doubt, cases are often 
complicated by blood poisoning from the absorption of the 
septic matter formed on the under surface of the decomposing 
membrane, in a manner analagous to that which occurs in 
surgical cases. Liability to this complication therefore must 
be somewhat in proportion to the size and thickness of the 
exudation. It is no doubt difficult to distinguish the effects 
of this septic material in the blood from the constitutional 
poisoning by the diphtheritic virus. 

Secondary blood poisoning might be suspected from the 
following symptoms arising during this process. 1. High, 
temperature, preceded or not by chills, followed in a few 
hours by perspiration and a decline of temperature, suc- 
ceeded, it maj' be, by a repetition at irregular intervals of 
chills, fever, and sweating ; feeble frequent pulse, sallowness- 
of the skin, and great prostration. 2. Increased adenitis- 
and cellulitis. 3. Formation of abscesses in the affected 
glands or in the joints. 4. Evidences of embolism. 

Third Period. The pharyngeal, faucial, and nasal or 
other surfaces are now supposed to be freed from the exudate- 
or false membrane which during the second period demanded 
such particular attention, and generally the period of con- 
valescence has fairly commenced. There remains little 



SYMPTOMS. 5^ 

ganger of the reformation of the membrane, and should it 
occur, the patient would still be regarded as in the second 
stas:e. 

Usually during the process of separation of these mem- 
branous patches, in the manner described, the more violent 
S}'mptoms abate, and in a majority of cases the patients need 
little subsequent professional care. Convalescence will 
probabl} T be uninterrupted if the patient have suitable nurs- 
ing, but all danger is not yet past. On examining the 
condition of the fauces or other surfaces from which false 
membranes have been removed, in the lighter cases, and, 
indeed, most others, no abrasion remains, and little or no loss- 
of substance having occurred, no cicatrix even marks their 
former location. The swelling and injection of the mucous 
membrane steadily subside. All local' discomfort is gone or 
rapidly disappears as the general sj-mptoms improve. 

The temperature and pulse rate are nearty normal, and 
remain so. 

The appetite is becoming good, and the urine of naturaL 
color and quality. The skin has resumed its functions, and 
the patient is beginning to move about. The muscular 
weakness is still considerable, and often apparent^ out of 
proporation to the preceding illness. 

Occasionally, even in cases like the above, the heart's ac- 
tion, still weak, may show signs of failure upon any exertion, 
and the patient may die suddenly from syncope. Ordinary 
cases, as well as grave ones, not infrequently are still liable 
to be affected with diphtheritic paralysis, which will presently 
be discussed. 

A few cases enter this third period with troublesome ulcers 
of the tonsils or fauces which may be slow of healing, as well 
as occasions of increasing the debility, and consequently 
augmenting all the dangers incident to this state. 

In cases supervening upon scarlet fever, and a few other, 
large abscesses of the glands of the neck are sometimes con* 



60 DIPHTHERIA. 

tinued into or are formed during this period, and with every 
care, occasionally have led to fatal results. 

Cases of secondary blood-poisoning extend into this period, 
the patient suffering from grave typhoid symptoms. These 
may gradualty sink into a profound coma, or suddenly die of 
cardiac embolism. Convalescence, if it occur, will probably 
be slow, tedious, and irregular. 

Paralysis is the only common, if not the only, sequel of 
diphtheria. The extreme debility which is observed in con- 
nection with and following severe forms of diphtheria, some- 
times resulting in fatal cardiac syncope, has sometimes been 
regarded also as a sequel, but should rather be regarded as 
characteristic of the disease itself. 

Paralysis never occurs during the first stage of the disease, 
and but very rarely during the second. A few cases have, 
however, been observed during this second or membranous 
period, of which the following is an example : 

E. W., aged thirteen years, attacked with diphtheria Oct. 
6th, 1878, was first seen on the 7th. Pulse 108, temperature 
102°, respiration accelerated, anorexia, and constipation. The 
countenance was dull, and deglutition extremely painful. The 
cervical and submaxillary glands were swollen and tender ; 
the faucial surfaces and tonsils were violently inflamed and 
were characteristically coated with tenacious mucus. Upon 
the velum and tonsils in several places were points of exuda- 
tion, and hoarseness indicated a like condition within the 
lar}-nx. Within a few hours these points extended rapidly 
and coalesced, presenting on the 8th an almost continuous 
surface of dense, yellowish- white, felted, tough, membrane. 
On the 9th the nostrils were stuffed and patclry, and the voice 
hoarse. By the evening of the 10th the laryngeal affection 
became so great that phonation was impossible and the breath- 
ing difficult and stridulous. On the 11th the visible mucous 
surfaces were nearly covered with a continuous dense mem- 
brane, and suffocation seemed imminent, and but for the fire* 



SYMPTOMS. 61 

quent inhalations of a five per cent, solution of chloral hydrate, 
must, in all probability, have terminated the case fatally. 
From this time to the 14th the struggle was continuous, and 
the result doubtful. 

"Wherever the membrane became detached from the soft 
palate it seemed relaxed and utterly incapable of retraction. 
As the surfaces continued to clear up, the voice was nasal, and 
deglutition and articulation nearly impossible from the mus- 
cular paralysis. This palsied state was carried over into and 
through the third period, and was hardly cured at the end of 
three months. Restoration was, however, finally complete. 
Trousseau mentions a case in which paralysis was manifest" 
three days before the disappearance of the false membrane. 
The occurrence of paralysis is usually, however, during the 
early part of the third period, and after convalescence has 
progressed from two or three days to as many weeks, or even 
after thirty or forty days. The accession is always gradual. 
It is observed by the attendants at first in defective articula- 
tion, nasal voice, or incapacity for suction. 

Deglutition is equally difficult. The paralyzed epiglottis 
allows portions of food to enter the larynx, occasioning spas- 
modic closure of the glottis and threatened suffocation. An 
attempt to swallow liquids results in their discharge in part 
from the nostrils, from paralysis of the muscles of the soft; 
palate ; a small portion enters the air passages causing stran- 
gulation, cough, and spasm. In occasional cases the paralysis 
affects the senses, as the vision, the smell, the taste, the touch, 
and also different sets of muscles, as those of the eye, the 
oesophagus, the arms, legs, &c. It very rarely affects the 
muscles of the bladder and rectum, and still more rarely those 
of the face. When single muscles only are affected, the ab- 
ductors usually suffer. McKenzie has seen two cases of per- 
manent paralysis of the recurrent laryngeal nerve following 
diphtheria. 

Diphtheritic paralysis affecting the vision is manifested 



62 DIPHTHERIA. 

variously. Some have amaurosis in various degrees, others 
have myopia, or presbyopia, or double vision, or unequal con- 
traction of the pupils, as a result of feeble and unequal sen- 
sibility to light. Strabismus has but rarely been observed. 
Dr. Reynolds has, however, reported a case in the New York 
Journal of Medicine, May, 1860, in which strabismus coex- 
isted with partial paralysis of the limbs, and the pharyngeal 
and cervical muscles. 

Of the extremities, the lower are generally first affected, the 
patient experiencing more or less tingling and numbness, fol- 
lowed or attended by trembling, and an uncertain wavering 
gait, which in severe cases increases to great awkwardness or 
•complete paraplegia. The power of muscular coordination is 
sometimes so deranged as to resemble chorea. The muscles 
-of the affected part feel soft and flaccid and are in a great 
measure insensible to electric currents. There is also more 
•or less impairment of cutaneous sensibilit}-. One or both 
arms ma}' be similarly affected. 

Inability to hold the head erect shows the muscles of the 
neck to be implicated, as in the case of Dr. Reynolds' before 
alluded to, in which the head fell forward upon the chest. 

Paralysis of the trunk muscles has also been observed, 
■deranging and impairing their action and likewise embarass- 
ing respiration 03*" the implication of the intercostals and 
other muscles of respiration. Paralysis of the diaphragm in 
proportion to its severity occasions dj^spnoea, and if complete, 
which is rare in all diphtheritic paralyses, must lead to fatal 
asplryxia. 

The sphincters are also in rare cases involved and occa- 
sion incontinence of urine or feces. Should the bladder be- 
come affected we might expect retention. 

An unlooked for fatal result, occurring suddenly, has some- 
times been attributed, with reasonable probability, to paraly- 
sis of the heart. 

No other contagious disease is so often followed by paralysis 



SYMPTOMS. 63 

as is diphtheria. Its cause has not been revealed by the vast 
labors bestowed in its investigation, and we are only able to 
say that it is one of the effects of the diphtheritic toxaemia. 
Brown Sequard attributed it to reflex irritation. Others at- 
tribute it to anaemia, to degenerative changes in the periph- 
eral nerves of the paralyzed parts, evinced by the disorganized 
state of the nerves seen in post mortem examinations, &c. 

The pathological changes observed in the nerves are not 
probably limited, however, to the affected parts ; but being 
occasioned by the general toxaemia, rather than bj 7 any special 
local cause, are general. What relation these changes bear to 
local paralysis, often remote from the seat of membranous 
exudations, is altogether conjectural. Sanne reports a case of 
paralysis in a child having no false membrane except upon 
the skin about the navel, and another, in which it was only 
observed upon one ear. 

The proportion of cases of diphtheria followed by paralysis 
has been estimated by Mansord at about ten per cent. Of 
the 1117 cases collected, it occurred in 111. 

The ratio of cases is probablj T not uniform and has been 
rated as high as 15 per-cent. 

According to Trousseau the operation of tracheotomy in- 
creases the proportion, or predisposes to the affection. 

Finally, all that is really known of this remarkable sequel 
of diphtheria may be condensed into a single sentence, thus : 
Its accession is insidious, generally beginning in the pharynx, 
is slowly progressive, continues for a variable period, and 
then still more gradually declines, and is rarely permanent 
or fatal. 



64 DIPHTHERIA. 



CHAPTER XL 
DIAGNOSIS. 

The diagnosis of diphtheria during the first stage is dif- 
ficult or impossible. There is hardty one of its symptoms or 
appearances but is common to one or more diverse diseases. 
We have stated before that the appearance of false mem- 
brane alone is diagnostic of diphtheria, hence a diagnosis 
based upon any other evidence, or all others combined, par- 
takes to some extent of the nature of guess work. 

Generally the physician is able at his first visit to recog- 
nize the disease by the presence of the pseudo-membrane, as 
he is not commonly called till patches in the throat have 
been discovered. When any difficulty arises, therefore, it 
will probably depend upon some deviation from its ordinary 
manifestations. 

The case may be diphtheria, and yet so mild in its type as 
not to occasion any membranous exudation, and therefore 
cannot be positively diagnosed. Again, the patient may be 
stricken down by such violent diphtheritic toxaemia as to 
die before a membrane forms ; diagnosis is here also impos- 
sible. 

In the first stage the question may arise as to whether the 
case is ordinary catarrhal sore throat or diphtheria. The 
known differences are so slight that only a histor}" of epi- 
demic prevalence or individual exposure can throw any light 
upon the question, and the diagnosis should be simply 
"doubtful." 



DIAGNOSIS. 65v 

In common sore throat in which the tonsils are covered 
here and there with patches of a grayish pultaceous deposit, 
easily removed, the deposit ma} T safely be pronounced non- 
membranous, but yet leaves the case in doubt. 

Is the case to be differentiated from thrush with patches of 
muguet on the tonsils ? The spots of elementary diph- 
theritic membrane may sometimes be distinguished by the 
greater difficulty of detaching the exudation, and the slight 
haemorrhage which follows its removal ; the product of 
thrush bring more easily detached and usually without 
bleeding. 

Diphtheria has very often been mistaken for scarlet fever, 
and vice versa. Although there are here points of resem- 
blance, there are also differences sufficient for a pretty safe 
diagnosis. There may be fever, sore throat, and possibly 
a papillary eruption, yet neither, separately, nor all combined, 
are diagnostic. We perhaps find the papillae of the tongue 
elevated and red, and place this appearance on the side of 
scarlatina. 

Fever characterizes both ; if the skin have a pungent feel f 
this too is indicative of scarlatina. In scarlatina the capil- 
laries are general 1} T congested, and the face and skin red; in 
diphtheria more frequently of natural color or rather pale. 
The constitutional disturbances are usually greater in scarla- 
tina than in diphtheria. The throat in the former is more 
uniformly reddened, often presenting the appearance of a 
papillary eruption, which is not seen in diphtheria. Albu- 
minuria may exist in either disease, and cannot be regarded 
as very significant. The rashes cannot be differentiated. 

In diagnosing diphtheria from scarlet fever, the histoiy of 
epidemic prevalence of either or both diseases, and of in- 
dividual exposure, must be considered. 

The diagnosis of diphtheria from membranous la^ngitis 
or croup is often difficult. Usually the diphtheritic laryngitis 
is accompanied by swelling of the lymphatic glands of the 
5 



66 DIPHTHERIA. 

neck, and is, moreover, often secondaiy in point of time to 
pharyngeal diphtheria. In croup the laryngeal affection is 
primary, and is not attended with glandular swelling. Some- 
times, as in a case quoted by Smith, subsequent events may 
reverse the diagnosis. a A boy, aged two years and ten 
months, died of acute laryngo-tracheitis, lasting about four 
da}*s. He lived in the suburbs of the cit} r , where the houses 
were scattered, and where there had been no recent diph- 
theria. The case commenced with hoarseness, which grad- 
ually increased to a fatal obstruction in the air-passages, 
without any pseudo-membrane upon the fauces or upon any 
other visible part. The case seemed to be identical with the 
true croup with which we were familiar before the occurrence 
of. diphtheria in New York ; and yet it was diphtheritic, for 
two or three days after the death of the child, the two j'onng 
women who nursed him, were affected with severe diphtheritic 
phaiyngitis, with the characteristic pseudo-membrane." 

Acute tonsillitis in its onset has manj^ points of resem- 
blance to the inflammatory t}^pe of diphtheria, as in both 
there is violent constitutional disturbance and acute inflam- 
mation of the tonsils. If the patient has been subject to 
quinsy, this fact will have weight in the decision of doubtful 
cases, as will also the prevalence of diphtheria in the com- 
munity. The practitioner may be compelled, at best, to oc- 
casionally endure a few hours of doubt while waiting for 
diagnostic developments. 



CHAPTER XII. 
PROGNOSIS. 

The mortality of diphtheria is without doubt exceedingly 
various in different epidemics, and is usually especially great 
in the earlier stages of its prevalence. In an epidemic which 



PROGNOSIS. 67 

prevailed in France in 1847, the mortalit}^ is stated b} 7 Sir J. 
R. Cormack as 91 per cent.; in the first quarter of 1876, in 
the hospitals of Paris, as 79.75 per cent., and in the preceding 
six j'ears as 76.54 per cent. According to authentic statistics 
of the Florentine epidemic in 1872 and 1873, 881 persons 
died out of a total of 1546 attacked, a mortality of over 
fifty-six per cent., which, Dr. Bergiotti remarks, should be 
regarded as rather the relation of the gravely affected to the 
dead, owing to incompleteness of the health returns and the 
probable omission of slight cases. 

I know of no means of arriving with certainty at the aver- 
age mortality of diphtheria. As already stated, it probably 
varies within wide limits. In Prof. Smith's report of cases 
in New York, the mortality was forty-seA^en per cent., of 
which he remarks, " The mortality of the cases embraced in 
the above table was probably larger than the average in New 
York practice, for several of them were seen in consultation, 
and their t}~pe was severe." 

Dr. Ringer {Boston Medical and Surgical Journal, Oct. 6th, 
1881), sa}-s, "According to the best statistics at hand, namely, 
those of our own city of Boston, two thirds of all reported 
cases recover, and the remaining one third die." With this 
Mackenzie agrees, saying, " It may, perhaps, be laid down as 
a rule that of the cases in which a definite membrane is 
present, one third, at least, will probabty prove fatal." About 
the same rate of mortality was exhibited in the recent epi- 
demic in the city of Brooklyn, N. Y. These rates accord with 
other American and European statistics, but are believed by 
the writer to be too high for a general average, which would 
probably range between twenty-five and thirty-three per cent. 

Few epidemic diseases can be shown to be nearly so fatal, 
«ven after making the most liberal deductions from these 
ascertained rates of mortaiitj 7 . 

Since fully adopting the chloral treatment in 1875, the 
author has treated upward of 400 cases of diphtheria, well 



68 DIPHTHERIA. 

characterized by false membrane, the only real diagnostic 
feature of the disease, with a loss of less than two per cent. 

In the first stage of the disease the dangers are almost 
entirely from severe blood-poisoning, in which the patient is 
in danger of sudden death from the toxaemia. In the second 
stage we have in addition to the dangers of the first, those 
arising from extension of the membrane to the larynx, or 
diphtheritic croup, and also in its later stages from septi- 
caemia from the absorption into the blood of the products of 
the decomposing exudation. In the former case the patient 
is in danger of death from asplryxia ; in the latter from 
asthenia. 

Infants at the breast are sometimes rendered wholly unable 
to nurse because of obstructed respiration. Such cases have 
been known to be fatal. 

Tihere is little doubt that in consequence of the diseased 
state of the kidnej's, patients are sometimes destroj'ed by 
uraemia ; the prudent practitioner should, therefore, carefully 
regard the character of the renal secretion in forming his 
prognosis. Again, in cases of marked debilhry, either from 
anaemia or any other cause, the heart's action is liable to fail. 
Dcbilit}*, therefore, is an important element in prognosis. It 
is impossible to estimate the danger to be apprehended from 
thrombosis and embolism, which in severe cases ma}' ensue 
at any period of the disease. Passive congestions and pul- 
monary oedema, also mainty due to debility or paralysis of the 
respiratory muscles, are not infrequently sources of great 
danger. I have several times known patients in these states 
to die as the immediate result of some exertion or excite- 
ment, as in opposing the administration of medicine, or in 
fits of anger. 

Among the symptoms to be regarded as indicative of ex- 
treme blood-poisoning, and hence as unfavorable to recovery, 
are blueness of the skin, with coolness, if even only of the 
lips and extremities ; extreme debilit} T with pallor ; anorexia 



PATHOLOGY. 69 

and persistent vomiting ; albuminuria, especially if accom- 
panied by vomiting ; implication of the nasal passages, 
denoted by stuffing or occlusion, with ichorous or fetid dis- 
charges, haemorrhages, and feeble or obstructed breathing. If 
the cause of obstructed breathing be the invasion of the 
larynx b} T the specific diphtheritic processes, the prognosis is 
most unfavorable. 

We should also regard a very rapid, a very slow, an 
intermitting, or an unsteady pulse as indicative of great 
danger ; as also a veiy high or very low temperature of the 
body. In patients affected with scrofula or having a sj-ph- 
ilitic taint the disease tends to become malignant, and there- 
fore the danger of a fatal termination is extreme. 

In any case having passed into the second stage, the 
danger is very generally in proportion to the extent and 
thickness of the false membrane. With adults, other con- 
ditions being similar, the prognosis is more favorable than 
with children, and for veiy obvious reasons. 

During the period of convalescence, paralysis constitutes 
the chief danger, which cannot be said to be great, unless it 
-extend to the muscles of respiration or to the heart, in which 
cases there is imminent peril. 

In all cases of diphtheria the prognosis should be so 
guarded that the occurrence of dangerous conditions, which 
cannot be predicted b} r the most practiced physician, may not 
reflect distrust or discredit upon the profession. 



CHAPTER XIII. 

PATHOLOGY. 

In general, during the first stage of diphtheria the fauces 
present the following appearances. The general mucous sur- 
face appears reddened, injected, and perceptibly inflamed. In 
malignant and secondary cases the color is more or less 



70 DIPHTHERIA. 

dusky. The- tonsils are swollen, and often upon their sur- 
faces are seen one or several elevated yellowish or grayish, 
mucoid spots, about a line in diameter. The parotid, sub- 
maxilla^, and often the cervical lymphatic glands are cb- 
served to be swollen. The uvula, too, in cases of considerable 
severity, is elongated and enlarged,, and the submucous 
tissues are similarly injected. Within a brief period, a few 
hours to a day, from the beginning of the inflammation, the 
spots upon the tonsils or uvula lose their equivocal character, 
and become specific and significant, as well as diagnostic. 

These patches gradually increase in size, become firmer 
and thicker from the exudation taking place beneath them, 
appear more dense and leather}', and constitute the pseudo 
membrane, the characteristic product of diphtheritic inflam- 
mation. 

When well formed and removed, this membrane has a 
somewhat felted appearance, or like the buffy coat of the 
blood. When handled it feels firm, is slightly elastic, and 
easily torn. If acetic acid be poured upon it, it swells and! 
is rendered transparent. The caustic alkalies dissolve it. 
Chloral solutions partially dissolve it, and cause its speedy 
disintegration. It is insoluble in water and in alcohol, and 
to the former 3'ields neither gelatin nor albumen, an indica- 
tion of its fibrinous character. Its thickness varies from a 
mere pellicle to one-eighth or even one-fourth of an inch. 
Under the microscope it exhibits a fibrous structure with. 
numerous bacteria and cellular bodies entangled or inclosed 
in its meshes. 

These membranes are found intimately connected with the 
mucous and submucous structures upon which they are pro- 
duced, and as shown before, can only be detached by consider- 
able force or by the means of inflammation and ulceration. 
Occasionally the ulcerative process does not stop with the 
separation of the false membrane, but gangrene results, and 
contrary to the more ordinary rule observed in the process, 



PATHOLOGY. 71 

there is considerable loss of tissue. In many fatal cases the 
gangrenous process is exceptionally active, and its offensive 
odor and its destructive energy are rendered painfully manifest 
during life, as well as upon the post mortem table. The idea 
of the ancient plrysicians, that diphtheria was gangrenous per 
se, was however derived solely from resemblance of the 
membranous exudation to a slough. The gangrenous process 
ma} T be, and doubtless is, generalty aided or caused by the 
injection of the submucous tissues with fibrinous elements, 
resembling that which has exuded to form the pseudo- 
membrane, together with the use of violent local treatment. 

" The exudation and infiltration sometimes compress the 
nutrient vessels of the part, and thus arrest the blood supply. 
Necrosis of the involved tissues results and leads to the 
formation of a slough, which is, in course of time, separated 
from the health}* parts. On the slough becoming partly 
detached there is left an open ulcer of various depth and 
extent." (Mackenzie.) 

Smith attributes the resulb " to the presence and contrac- 
tion of the fibrin with which the mucous membrane is in- 
filtrated." In this manner are sometimes destroyed portions 
of one or both tonsils or the uvula. 

The mode in which these membranes are produced will 
be readily understood by the following from Beale on Disease 
Germs : " The transparent colorless fluid which moistens 
the surface of a superficial wound after it has ceased to 
bleed, is poured out from the capillaries, or from the Emph- 
atic vessels, or from both sets of vessels. This fluid, besides 
containing albumen in solution, contains multitudes of minute 
particles of bioplasm, which grow and multiply upon the 
surface. These form fibrin and matters more or less allied to 
it, and perform an essential part in the healing process, or in 
the formation of pus, as the case may be. These minute 
particles of living matter are present in the blood and tymph 
in countless numbers. They are concerned in the production 



72 DIPHTHERIA. 

of fibrous tissue outside the capillaries, which takes place in 
many pathological processes, and also in the production of 
pus-corpuscles, and other 'corpuscles' in the same situation, 
in disease. All exudations contain these particles of living 

matter. When the capillary vessels are distended, as in 

that extreme congestion which soon passes into inflammation, 
a fluid which possesses coagulable properties transudes 
through the stretched capillary walls. It is probable that in 
such cases minute and narrow fissures result, which, however, 
are too narrow to allow an ordinary white Or red blood corpus- 
cle to escape, but, nevertheless, wide enough to permit many 
of the minute particles of the living or germinal matter, the 
existence of which in the blood has been already referred to, 
to pass through. The small protrusions upon the surface of 
the white blood corpuscle might grow through the capillary 
walls, become detached, and pass into the tissue external to 
the vessels. Such minute particles of living matter external 
to the vessels, being surrounded with nutrient pabulum, and 
stationary, would grow and multiply rapidly, while a similar 
change would of course go on in the now stagnant fluid in 

the interior of the capillary. Some of these active 

living particles may be so small as to be invisible by a power 
magnifying 5000 diameters. I have seen such particles less 
than the 50,000th of an inch in diameter, and have no reason 
whatever for assuming that these are really the smallest that 
•exist." 

The bacterian bodies found in these membranes may be in 
great part derived from the blood, the tissues, or the air, in 
all of which under favorable conditions they are shown by 
this distinguished author to abound ; and of the same varie- 
ties as that of which Eberth declared, lm Without micrococci 
there can be ?io diphtheria" Beale further states that he finds 
vegetable germs in every part of the bocty, and that they 
probably exist there from the earliest age and in all states of 
liealth ; that millions are always present on the dorsum of 



PATHOLOGY. 73 

the tongue and in the alimentary canal ; that if in their active 
and not in a germinal state they be introduced among the 
living matter of healthy tissues they will die, although their 
minute germs which escape death ma} T remain embedded in 
the tissues in a perfectly quiescent state. 

Senator considers the minute round bodies described by 
Oertel as Spherical bacteria, to be the spores of the Lepto- 
thrix buccalis, and says the same fungi are found in diph- 
theria as in stomatitis. By other competent observers the 
bacteria of diphtheria are found in no way different from 
those observed in small pox, typhoid fever and vaccina. 
Although these bodies abound in the membranous exudate 
of diphtheria, their origin is not obscure, nor do they stand 
in a causative or other necessan~ relation to the disease. 

These membranes, excreted from the blood, are shown under 
the microscope to be composed of fibrinous bands, in the 
spaces or interstices of which are found abundance of bac- 
teria and numerous cells and granular matter as before stated. 
" No certain and invariable chemical or microscopical differ- 
ence has yet been established between the pseudo-membrane 
of croup and that of diphtheria. The difference universally 
recognized is this : that while the croupous membrane lies 
upon the mucous membrane, and does not penetrate it, that 
of diphtheria, in the localities where it most commonlj- forms, 
namely, upon the buccal, faucial, and laiyngeal surfaces, 
penetrates and becomes blended with the mucous membrane, 
so that it cannot be detached by force without the risk of in- 
juring this membrane, and lacerating its vessels ; moreover, 
by its presence in the mucous laj-er, it is apt to obstruct cir- 
culation in it and cause ulceration, even in the submucous 
tissue." (J. Lewis Smith.) 

The septicaemia previously alluded to, most frequently occurs 
in cases in which, from decomposition of the membrane and 
the blood exuded beneath it, the exudate has assumed a dark 
color and become friable, causing ichorous discharge and fetor 



74 DIPHTHERIA. 

of the breath. Absorption of this diseased material causes in- 
flammation of the tymphatic vessels and glands, or increased 
adenitis, which also occasions inflammation of the perigland- 
ular structures. On section the glands appear redder than 
natural with evident increase in their cell elements. The sur- 
rounding tissues are found infiltrated with serum and pus- 
cells. The parotids and submaxillary glands are similary 
affected and frequently contain small collections of pus. 
The bronchial tubes are almost always more or less inflamed, 
and in some cases are the seat of membranous exudation 
which often extends to those of smallest calibre, and in these 
cases fibrinous bands extend into the alveoli, forming a 
network containing pus and at times blood corpuscles and 
bacteria. 

The lungs are generally somewhat engorged and oedematous,. 
especially at their bases. Pneumonia of a low tj-pe is also 
quite common, and may be either lobar or lobular, catarrhal 
or diphtheritic. 

The heart ma}- appear healthy, but in death from toxaemia 
its tissues are found soft and friable from fattj- or granular 
degeneration, and of a color that has been compared to new 
leather, or coffee and milk. In some cases its chambers con- 
tain fibrinous coagula of antemortem formation, and a not 
infrequent cause of death. Similar coagula are found in the 
larger blood-vessels, blocking up the channels of the circula- 
tion. We cannot avoid again calling attention to the con- 
stant tendency manifested in diphtheria in almost eveiy local- 
ity, to the coagulation of the fibrinous elements of the blood. 
The loss from the circulating blood of the fibrin abstracted 
t>y this coagulation within the glands and blood-veseels, as- 
well as upon the surfaces of the body, greatly impoverishes 
it, and, with its impairment or decomposition within the 
bloodvessels, is chiefly the cause of its comparative incoag- 
ulability when abstracted by phlebotomy. Back of this lies, 
of course, in a causative relation, the original septicaemia. 



PATHOLOGY. 75 

induced by the subtle contagium generated in the body of 
some other person previously affected with the disease. 

This great loss or destruction of fibrin robs the blood of 
its vital and nutritious properties, and in connection with 
other effects of the blood poison is doubtless the cause of 
the ever noted asthenic phenomena of the disease. 

In 1872 Dr. Johnson, as quoted by Mackenzie, put forward,, 
as the result of a careful comparison of many accuratel}' re- 
corded cases, the view that cardiac thrombosis is of very fre- 
quent occurrence in cases of diphtheria, and is a very fertile 
cause of their fatal termination. He also described in detail 
the physical signs by which its occurrence might be diag- 
nosed during life. These views have been controverted by 
M. Collandreau Defreese, and the phenomenon attributed to 
antecedent cardiac disease, rather than to the diseased state 
of the blood ; but be it observed that it is not in the heart 
alone the tendency to coagulation exists, but it is manifested 
also in the lungs, the glandular structures, upon the mucous sur- 
faces, and upon wounds, and veiy probably throughout the vas- 
cular system ; showing, in the author's judgment, the antece- 
dence to belong to the blood and not to the heart. Again, this 
condition of the blood is shown in the earliest stages of the 
disease, before the period of cardiac complications or thrombosis 
is manifested, and is one cf the evidences before noted of pri- 
mary blood-poisoning in diphtheria, and points significantly to 
such haematics as remedies as are known to possess the power 
of preventing such coagulation and of thus limiting the forma- 
tion of an exudation. 

The brain manifestations depend largely upon the mode of 
d}ing. If death be from asphyxia, there are found venous 
congestion with minute extravasations of blood. Pus and 
lymph may be found upon its membranes in cases of severe 
toxaemia, and certain degenerative changes have been ob- 
served in the peripheral nerves and muscles affected b}~ diph- 
theritic paratysis. M. Charcot found certain nerve C3iinders > 



76 DIPHTHERIA. 

from a paralyzed palate, nearty or quite destitute of medullary 
matter, and to contain fatty granules of elliptic form, some of 
which were nucleated. 

Neither the liver nor spleen have been shown to present 
an}' uniform lesions characterizing the disease. 

The kidneys are more frequently found affected than any 
other internal organs, as from their anatomical situation and 
physiological function, as well as from the toxsemic character 
of the disease, they seem more exposed and overtaxed than 
any other viscera. 

The blood in diphtheria, as before remarked, exhibits de- 
rangements, such as, from the disease phenomena noted, 
might reasonably be expected. From its necessary poverty 
of fibrinous elements it forms but an imperfect, soft, ill-de- 
fmcd coagulum. In cases of death Iry asphyxia from the 
laryngeal form of the disease, as might be inferred, it is 
"blackish from excess of carbonic acid. Some observers have 
noted an undue proportion of white blood corpuscles in diph- 
theritic blood, as in other forms of asthenia, as anaemia and 
chlorosis. It has also been observed to show evidences of 
decomposition from the effects of the diphtheritic poison, by 
the abnormal accumulation of dark-colored debris. In 
man}- of the organs are found small exudations of blood, as 
already observed. These are most constant within the cra- 
nium, and are common in the lungs, the kidneys, and the 
spleen, and have been observed in the coats of the stomach. 

" The most cursoiy study of the general pathology of diph- 
theria suffices to assure us that it is an acute general disease 
with certain local manifestations. The primary septicemia 
is due to the specific poison, but absorption from the decom- 
posing lymph is, no doubt, a cause of secondary infection. In 
all cases, the attack is associated with some degree of consti- 
tutional disturbance, while in the severest forms there is ex- 
treme disorganization of the blood, and consequent implica- 
tion of nearly every tissue of the body. The general infec- 



GENERAL TREATMENT. 7T 

tion is shown at a very early stage, as well as at a period 
when the local manifestations have disappeared. Besides the 
constitutional disturbance, by which the attack is ushered in, 
there is the frequent derangement of the renal function, the 
marked prostration of strength, the functional disturbance of 
the heart, and, at a later period, the extensive implication of 
the nervo-muscular sj'stem. The local sj'mptoms — the false 
membrane, with its parasitic growths — must be looked upon 
as the first (?) evidence of constitutional poisoning ; in fact, 
as the first of the secondary phenomena." (Mackenzie.) 



CHAPTER XIV. 

GENERAL TREATMENT. 

Having shown diphtheria to be, as defined in chapter I., an 
acute, infectious, specific, febrile, disease, depending primarily 
upon infection of the blood, manifested not only by general 
symptoms, but also by a peculiar and often dangerous specific 
inflammation ; and having described the type and course of 
both, and the pathological phenomena they severally exhibit ; 
and also the complications incident to the several types and 
stages of the disease, with their significations and tendencies ; 
there yet remains for. us to consider its treatment. This will 
be done under the heads of General, ^Therapeutic, and Pro- 
phylactic treatment. 

The remarkable mortality hitherto exhibited by diphtheria 
under all the various modes of treatment hitherto practiced, 
amounting to from twent3 7 -five to ninety-one per cent of the 
persons attacked, as estimated by several of the most trust- 
worthy modern observers and authors (See Chapter XII), 
gives to this portion of our work peculiar interest and im- 
portance, and is a sufficient warrant and excuse for putting 



78 DIPHTHERIA. 

forward and defending the peculiar and novel mode of thera- 
peutic treatment introduced by the author, and herein first 
given to the profession. 

Without disavowing the ordinary motives prompting to 
research and labor, the writer distinctly claims the chief 
motive in view in giving these pages to the medical profes- 
sion is a desire to diminish the sum of human suffering and 
the ravages of death from this fearful malady. 

As diphtheria is a disease manifested lyy great depression 
of the bodil}' powers, the general treatment should be sup- 
porting. The patient should be placed in the best available 
apartment, which should be large, cheerful, well-lighted, well- 
ventilated, and well-warmed. As a general rule the tempera- 
ture should be such as is most comfortable to the patient, and 
hence should be varied in different stages and cases to gratify 
his demands. The limits of variation may properly be be- 
tween G0° and 75° F. When the larynx is invaded, moisture 
diffused in the atmosphere of the sick room is of signal 
benefit. 

Whatever be the means of ventilation, keep the air pure 
and sweet, and its odor may be rendered agreeable by the 
use of pleasant perfumes. Keep the patient out of cold 
draughts. 

The food must be not merely nutritious, but nicely pre- 
pared, fresh, and agreeably flavored. It ma} 7 consist of 
sweet or buttermilk, eggs, tender beefsteak well hashed 
while raw, and lightly cooked, scraped beef, beef-tea or 
essence, egg-nog, milk-punch, soft cream-toast, rice thoroughly 
cooked, rice water, toast water, &c, and given regularly and 
frequently, day and night, in such quantities as are well 
borne. A little lime water ( 3 i ad 3 ii to 3 i) renders sweet milk, 
it is thought, more digestible. Food ma} 7 be disrelished or 
swallowing very painful, still it should be given in some 
eligible form, or by enemata if that be the only available 
way. Most children will drink freely of cold fresh milk or 



GENERAL TREATMENT. 79 

buttermilk ; if, however, it agree better, let it bo warmed. If 
milk be taken freely, especially if a little raw egg with sugar 
be added, no fear need be entertained of want of nutrition. 
A high authority has recently stated, " There are few cases 
-of diphtheria in which sj^stematic feeding does not constitute 
the most important part of the medical treatment." 

In cases of marked anorexia, or of continued nausea and 
vomiting, to force into the stomach large quantities of food 
■only to be ejected, or that can at best be but sparingly 
assimilated, is dangerous and reprehensible, and hastens 
rather than retards the rapid emaciation, and lessens the 
patient's chances of recovery. This is true equally with 
adults and children. Among the latter are found many who, 
born to rule, have never been taught proper subjection to 
authority, and hence are, by most emphatic exhibitions of 
will, in the habit of controlling all about them b} T the force 
of unreasoning passion and resistance ; and, also, the timid 
and over-sensitive class, who, from their loathing of food and 
medicine, painful deglutition, enfeebled powers, and unwonted 
surroundings, are bereft of their accustomed docility. Both 
these classes of children, when crowded by force, often resist 
.absolutely necessaiy treatment with so great excitement and 
physical exertion as greatty and dangerously to exhaust their 
prostrate powers, thus increasing the imminent perils of 
disease. 

Here arises a necessity for discrimination and the exercise 
of tact, often more potent for good than drugs, or even food 
administered unwisely or forcibly. Yield what is necessary 
in order to conquer peacefully. A little gratification of some 
longing desire, a little praise or sympathy well expressed, a 
little quiet repose, a firm look or word, or expressive gesture, 
or the exercise of an} r of the nice arts that spring spontane- 
ously ffom the breast of sympathy or affection, will some- 
times remove mountains of opposition, and are not to be 
neglected. 



80 DIPHTHERIA. 

Make the necessary food and medicines as agreeable a$ 
possible j manage the patients well, and they will submit to- 
necessary general or therapeutic treatment. 

Sinapisms to the epigastrium or spine for older patients, or 
bits of lint or brown paper wet with chloroform or chloroform 
liniment and held in place with the hand a few moments r 
and, for children, spice poultices containing half a drachm of 
chloroform, are well borne and beneficial. A small glass of 
lemonade, iced or hot, as is thought best, or a litte freshly 
prepared tea or coffee arc to be commended, as also arc any 
aromatic mint or ginger teas. Recourse may also be had to 
the remedies advised in chap. XVI, or the formulae appended 
to this volume. 

In every case of marked debility, and such constitute a 
large proportion, the use of alcohol is indicated, in quantity 
proportioned to the condition and age of the patient. Three- 
or four drachms of brandy or pure whiskey in twenty-four 
hours for a child of three or four 3'ears, given in punch or 
milk and egg mixture, may suffice in cases of only ordinary 
depression. In similar conditions an adult may take an 
equal number of ounces. Attacks of fainting, irregular, very 
slow, or very rapid pulse, sighing, great pallor or duskiness 
of countenance, or stupor or delirium, are each among the 
symptoms calling for a more liberal administration of this 
class of stimulants, regardless of body heat. If, however, in 
cases of high temperature with rapid pulse, these be increased, 
the stimulant is of doubtful propriety, and had better be 
diminished or suspended. 

The character of the pulse should be carefully noted as 
one of the chief criteria in the use of any form of alcoholic 
stimulus. From the overwhelming effects of the severe 
toxaemia of diphtheria, manifested by feeble action of the 
heart, or the occurrence at any period of the disease of great 
exhaustion, it' should be given liberally ; in great emergencies, 
unsparingly. 



THERAPEUTIC TREATMENT. 81 

The patient's clothing and that of the bed should be 
changed daity, and oftener if they become soiled, and ex- 
crementitious matter immediately removed. Time must be 
given the patient for sufficient sleep, espeeialty during the 
night. 

No persons except necessary attendants and unexcludable 
relatives should be allowed to visit the sick room. All un- 
pleasant odors, especially from the kitchen, must be excluded, 
and the most rigid order and quiet enforced. 

The patient should have a general tepid sponge bath once 
or twice a day, following which the skin, if hot and dry, may 
be rubbed with a little olive oil, to which may be added a 
few drops of carbolic acid or agreeable perfume. If the skin 
be too much relaxed, the bathing should be with alum-water 
and alcohol. 

Other details of the hygienic treatment are omitted as 
needless for intelligent doctors into whose hands only, or 
chiefly, is this volume expected to find its way. 



CHAPTER XV. 
THERAPEUTIC TREATMENT. 

An eminent writer says, " Few diseases more severely tax 
the therapeutic resources of the physician than diphtheria." 
"Why ? It is, as stated, because " he has to devise and carry 
out innumerable little details — hygienic, dietetic, and medi- 
cinal — which do not admit of description, and yet, upon the 
minutiae of which, success or failure depend ; because, too, of 
its various types and degrees of violence ; and mainly, I 
apprehend, because the records of diphtheria disclose no 
authoritative, established, generally acknowledged, or even 
reasonably successful mode of treating the disease. 
6 



82 DIPHTHERIA. 

The diversity of the therapeutic measures advocated 
amounts to little less than confusion, and tends to beset the 
prevailing distrust of all authorities and all remedies, and to 
drive each individual member of the profession to trust him- 
self to "devise" from his own resources, measures of treating 
the symptoms of each individual case as the}' ma}' occur. It 
may appear to some to be a reflection upon medical science, 
to be so barren of acknowledged facts, as to be forced to such 
an acknowledgment in so vital a matter. Such, however, is 
not the fact. Medical science is not a revelation, like 
theolog}' ; nor demonstratively exact, like mathematics ; nor 
so palpable as physics ; but, like chemistry and electricity, 
has grown from the minutest germ, into a structure so stately 
as to rival all its contemporaries. In this stately edifice 
each stone is a golden fact, worked out from the quarries of 
eternal truth by patient research and careful observation. 

From its very nature medical science can never be com- 
plete, but must be ever progressive, and this state of inhar- 
mon} T and unrest is only the earnest of progress. It is 
unreasonable to expect the votaries of this science to rest 
quietly in the presence of a mortalit} 7 so appalling as is 
disclosed in the records of diphtheria. Inaction would be 
disreputable, non-professional, criminal. The search for a 
better, for a specific therapy in diphtheria will continue 
despite the taunt of "a hobby," ignoring a blind deference to 
the dead past, refusing servile submission to the dogmas of 
the present, until the goal is reached, and the prize shines in 
the diadem of the victor, embellishes the great temple of. 
medical science, and becomes a blessing to the human race. 

All honor, we say, to Bretonneau and his compeers, the 
heroes of general and local blood-letting, of blisters, of caustics 
to the pharjmx, and of mercury. Dr. Bard wrote, " But al- 
though I consider mercury the basis of cure, I do not b} T any. 
means intend to condemn or omit the use of proper alex-, 
ipharmics and antiseptics." 



THERAPEUTIC TREATMENT. .83 

These authors of the past belonged, as leaders of medical 
thought, to their own da}' and generation, and not to ours, 
and if we judge them by our own standards we judge them 
unjustly, because the inarch of progress has been forward. 
Occasionally onl} r , in this age, can be found an irrational 
advocate of mercurial treatment, whilst, with our better 
knowledge of the asthenic nature of diphtheria, the blood- 
letting and blisters, with all other depleting measures, we of 
the present day treat as madness. A few high names may 
still be quoted in advocacy of strong caustic applications to 
the throat, among whom we may mention West, Bouchut, 
Trousseau, Slade, Qertel, and Aitkin. Fortunately for the 
interests of humanity, as well as in honor of the medical 
profession, in obedience to the advancing sentiments of the 
age, these and all other violent measures of treatment are 
being abandoned. 

With regard to the want of harmoiry in modes of treat- 
ment by different practitioners, J.L.Smith writes: "The 
•wide discrepancy which exists in reference to the proper 
therapeutic measures, receives partial explanation from the 
fact of a wide difference of opinion as to the nature of diph- 
theria and its mode cf commencement, but is more often due 
to the fact that statistics of its treatment afford very unrelia- 
ble and often conflicting data, by which to determine the 
proper medicinal agents. 

" For scarcely an}' other disease presents such a diversity in 
type as diphtheria, from cases so mild that nearly all recover, 
whatever the measures employed, to those so severe that a 
large proportion die under the best possible treatment, and 
this difference in t}-pe may be observed in cases occurring at 
the same time in a great cit}^ like New York, or even in the 
cases, which two plrysicians, practicing near each other, may 
be called upon to treat. Hence, one physician recommends 
with confidence a medicine or mode of treatment, as eminent- 
ly successful in his hands, of which another physician of equal 



84 DIPHTHERIA. 

experience speaks disparagingly. The theory relating to 
diphtheria, which, in my opinion, has of late years done most 
harm, is that which attributes it to low vegetable organisms, 
visible under the microscope, which alight upon one of the 
exposed surfaces, usually the fauces, where they excite a 
local inflammatory action, and if not promptly destroyed, are 
apt to penetrate the tissues, enter the blood, and establish a 
constitutional disease. Acceptance of this theory evidently 
leads to the employment of parasiticide medicines, the so- 
called antiseptics, or antiferments, externally and internally, 
to arrest and destro}^ the vegetable growth, their local use 
sufficing, according to the theory, in the early stage, when 
these organisms have passed no further than the surface ; but 
their internal use being required in addition, if the malady 
have continued longer, and the disease have become general." 
Therapeutic treatment is divided into local and general or 
constitutional. 



CHAPTER XVI. 
LOCAL TREATMENT. 

NUMBERS OCCURRING IN THE TEXT REFER TO THE FORMULAE AT THE END OW 

THE VOLUME. 

We have already incidentally alluded to the " savage ener- 
gy " of the local measures advised by Bretonneau and others. 
The propriety of local treatment of its local manifestations 
is not to be questioned in diphtheria, any more than in other 
constitutional diseases with local manifestations, as in 
syphilis, scrofula, rheumatism, mumps. We must be careful, 
however, to put only a cautious and limited trust in our local 
measures, as some in use only increase the local irritation, 
and none are curative of the constitutional affection. Dr. 
Bristowe, in the Medical Times and Gazette, 1859, may be 
regarded as leading the modern sentiment on this subject. 



LOCAL TREATMENT. 85 

He says, " 1. That the throat affection is merel} 7- a local evi- 
dence of a constitutional disease, which is unlikely to be 
arrested in its progress by any treatment directed to the 
secondarjr manifestations only. 2. That the throat affection 
rarely kills, except by involving organs, such as the trachea 
and deeper tissues of the neck, which are beyond the region 
of the possible influence of such agents. 3. That if the 
theoretical correctness even of such treatment be admitted, 
the application of remedies to the surface of a thick false 
membrane, with the hope that they may affect the adjacent 
mucous tissue, is not onty clumsy, but, as regards the object 
intended, practically useless ; and that the prior forcible 
removal of the membrane from the entire surface, in order to 
their efficient employment, is unjustifiable in the early stage, 
even if possible, and is likely only to be followed by in- 
creased inflammation, and reproduction of false membrane. 
Of course, if a gangrenous state of the tonsils, or any other 
local complication, supervenes, such topical applications as 
are commonly had recourse to in like conditions of the throat 
should be employed." 

Mr. Wade, in 1862, expressed the conviction that interfer- 
ence would neither prevent the reproduction of the false 
membrane, nor prevent its extension to the larjmx. Green- 
how's maturer views may be inferred from the following 
language : " I very soon discontinued this rough local 
medication to the tender and enfeebled mucous membrane. 
The propriety of this course became evident at the very first 
post-mortem examination I had the opportunity of witness- 
ing, and has been confirmed by my subsequent experience." 

Dr. Hartshorne recommends the use of hydrochloric acid 
and hone}^, equal parts, painted over the surfaces, or diluted 
and used as a gargle, also creosote in glycerine ; lime-water ; 
ice ; and the inhalation of lime-water steam. 

Aitkin advises warm fomentations externally, and the in- 
halation of water vapor with acetic acid : he also thinks a 



86 DIPHTHERIA. 

gargle, composed of a fluid drachm of diacetate of lead in 
eight ounces of rosewater, may be of service, but saj-s gargles 
must not be persisted in if pain be caused by their use. 
" The tincture of the perchloride of iron is now fully recog- 
nized as having a beneficial local as well as general effect, 
and may be advantageously combined with quinine." He 
advises that the throat be S}'ringed with a solution of per- 
chloride of iron, and that the exudation be painted with a 
strong solution of the same, and also recommends a single 
efficient application of nitrate of silver, or equal parts hydro- 
chloric acid and water, and considers useful a gargle of 
medicinal carbolic acid, one part in a hundred. 

Cohen does not think highly of local applications or 
gargles. 

Fothergill recommends the free use of nitrate of silver, 
as also do West and others. 

Oertel, in Ziemssen's Cj'clopsedia, says, " In diphtheria 
we have to deal at first with an infection which is localized, 
and afterward with a general disease resulting from this, 
out of which maj T ultimately be developed still a later infec- 
tion of various organs." As disinfectants, to be used with 
the atomizer, he advises chlorate of potash, salicilic acid, 
and, in the more advanced septic states, permanganate of 
potash. (See formulae at end of volume.) 

Prof. Smith says the object of local treatment is "to* 
reduce the inflammation of the mucous surfaces, and destroy 
the diphtheritic poison, and contagious properties in the 
pseudo-membrane, and to destroy the septic poison, and 
prevent its absorption, if any forms. Irrigating applica- 
tions, the use of the sponge or other rough instrument for 
making the application, should be avoided as likely to do 
harm." He advises the application to be made with a larga 
camel's hair brush, or better, for most mixtures, with an 
atomizer. , 

v In laryngeal cases; he .considers lime-water spray the most 



LOOAL TREATMENT. 87 

efficient, and reports seven recoveries in twenty-five cases 
thus treated. He advises the inhalations to be nearly con- 
tinuous. For cleansing and disinfecting the nasal passages 
he advises Form. No. 8. A very excellent spray solution may 
be made by the mixture of lime-water and carbolic acid. 
Favorable effects are reported from dusting the affected parts 
freely with washed or sublimed sulphur. 

Prof. M. Mackenzie writes, "In fact, the profession has 
given up the use of caustics altogether," and in regard to 
various astringent applications, as tannic acid, powdered 
alum, and tincture of the chloride of iron, " The disease is 
sometimes checked by this class of remedies, but on the other 
hand they sometimes irritate the throat — especially if there 
is much hyperemia — and frequently increase the nausea and 
dislike for food which are so common. I now seldom use 
these drugs with the exception of iron, which when emploj^ed 
as a constitutional remecty also acts topically." 

The objects had in view in the local treatment of diph- 
theria may be thus briefly summarized : 1st. Cleansing the 
mouth, throat, and air-passages ; 2d. Disinfecting their secre- 
tions ; 3d. Alla} T ing inflammation b} T promoting secretion ; 
4th. The solution of the membrane or its detachment. 

Two, three, or even all of these indications may be more 
or less perfectly fulfilled by a single remedj". Thus washing 
the mouth and throat thoroughly with warm water or weak 
solutions of chloral hydrate, borax, or chlorate of potash, 
purifies the surfaces, measurably disinfects the secretion, 
and promotes secretion and the detatchment of the false 
membrane. 

But it is well known that sick children are very generally 
refractory, and by reason of perverseness, fear, or nervous 
irritability, or all combined, refuse to gargle, and resist 
any efforts to wash thorough^ the mouth, throat, or nasal 
passages. To force them into submission is to exhaust the 
strength and vitairty; alread\ r , it may be, alarmingly de- 



88 DIPHTHERIA. 

pressed, and which are so necessary to any satisfactory 
treatment, and to recovery. Let there be no occasion given 
the little sufferers to either fear or fight their medical atten- 
dants or nurses — rather let them be coaxed, cajoled, or 
hoaxed into the use of the best available measures. 

Some quietly submit to topical applications with a large 
soffc camel's hair brush, which should be rinsed in hot water 
as often as it becomes loaded with the viscid secretions. 
For use in this manner or for gargling, formulae Nos. 2 and 3 
are specially recommended. 

For cleansing and disinfecting the nasal passages when 
involved in the diseased action, inject three or. four times a 
day the weaker solutions Nos. 6 and 7, or Prof. Smith's 
solution No. 8. 

Avoid caustic and irritating applications, as they greatly 
aggravate the local mischief by coming unavoidably in con- 
tact with and destroying parts of the pharyngeal and laryn- 
geal surfaces not yet invaded by .the exudation, thus making 
new foci for the appearance and diffusion of the membrane ; 
by impairing the ability to take nourishment, and, from the 
pain they occasion, engender opposition and strife on the 
part of the patient ; and increase the absorption of septic 
matter. 

No other local application has proven of equal value in my 
practice with chloral hydrate. I have used it constantly and 
exclusively for the last six j^ears in every form of the disease, 
and in not less than four hundred cases, and can confidently 
affirm its great superiority, if not its specific control over 
membranous exudations, especially when used constitution- 
al^ at the same time. 

In cases of but ordinary violence in which the air-passages 
are not invaded, the contact by gargling and swallowing, or 
simply swallowing the solution prepared for internal use 
hourly, prohibiting drink or gargling for five minutes after 
the administration, proves quite sufficient ; both the local 



LOCAL TREATMENT. 89 

and constitutional s} T mptoms beginning in a few hours to 
abate. The average duration of such cases has been about 
four days, exceptionally longer or less, with no other medical 
treatment. The ordinary sequelae rarely occur to retard the 
convalescence in these cases, the proportion thus affected not 
being above two or three percent. 

When the nasal passages are involved in the diphtheritic 
process, as evinced by the symptoms detailed, they should 
be carefully cleansed and disinfected b}^ Sj'ringing with weak 
solutions of chloral every four hours, (Formulae Nos. 6 
and 7). 

Regarding the topical use of chloral, Prof. Mackenzie says, 
" It was first recommended b} r Dr. Accetella, and subsequently 
by Dr. Ferrini, of Tunis, and has since been highly extolled 
by Dr. Csesare Ciattagli, of Rome, and Dr. Massei, of Naples. 
In this country (England) it has been employed with great 
success by Mr. Hughes Hemming, of Kimbolton, to whom I 
am indebted for its recommendation. Mr. Hemming uses 
the syrup of chloral (grs. xxv in 3 i) and directs that it 
should be employed every hour or two. It does not, as 
a rule, cause any pain, and the nurse can easily be taught to 
apply it. Mr. Hemming observes that 'whilst it rapidly gets 
rid of the fetor, it is beautiful to see the membrane loosen 
and come away, leaving a healthy surface underneath.' 
This remedy has also been very successfully used by Dr. 
€harles Hemming, of Bishop's Waltham." 

The following testimony of the remarkable efficacy of 
chloral, topically applied, is borne by Dr. Rokitansky in the 
Medicinisch-Chirurgische Rundschau, Nov. 1878, as quoted 
by the American Journal of Medical Sciences, April, 1879. 

"Dr. Rokitansky has used a 50 percent solution of 
chloral in three cases of diphtheria which had resisted the 
usual remedies, such as salicilic acid, carbolic acid, &c, and 
every time with the same results. The solution was applied 
every half hour with a camel's hair brush, and caused very 



90 



DIPHTHERIA. 



little pain, except m one case where the tongue was thickly 
covered with a layer of diphtheritic matter ; here a very con- 
siderable secretion of saliva was always observed immediately 
after the application, and the pain ceased entirety after a few 
moments. In the other two patients, in whom both tonsils 
were partly covered with the diphtheritic membrane, the pain 
was insignificant. 

' ; After the solution had been applied three times, i. e., one 
hour and a half after the first application, large pieces of the 
membrane could be easily removed with the brush. The 
underlying portion of the mucous membrane was red and 
covered with fine granulations. As soon as the normal tis- 
sue could be seen, weaker solutions of chloral were gradually 
used during a week, at the end of which the patients had 
entirety recovered." 

I have rarely used for the last five or six years an}- other 
topical treatment within the throat, and therefore feel qual- 
ified to indorse the preceding testimonials of its remarkable 
efncac} T , and to a*ecommend chloral for this purpose as more 
effective than an} T other remedy. According to m}- observa- 
tions it will not only cause a rapid separation of the false 
membrane in mass, but so act upon it also as to cause 
its disintegration, thus depriving it of its structural charac- 
ter and much of its power for mischief. In this manner the 
exudate can often be defibrinated as fast as transuded, and 
its membranous or structural character be prevented. 

Its local application should be by means of a soft pencil 
of camel's hair or a feather, and when the constitutional 
treatment is also by chloral, and timety, will seldom be 
required and need never to be repeated more than two or 
three times a day, and in strength of from twenty to fifty per 
cent. 

The patient, if it be agreeable to him (but not otherwise),, 
maybe allowed to take, small pieces of ice frequently into 
the mouth as a means of allaying thirst and morbid heat and 



LOCAL TREATMENT. 91 

dryness. It is thought by some also to have the effect some- 
times of reducing the local inflammation and swelling about 
the fauces. This, however, there is ample ground to doubt, 
and when we consider the nature of the disease, and the 
peculiar low grade of the inflammation, there is good reason 
to fear harm from its effects upon the obstructed capillaries 
of the parts, b} r causing in them a decrease of the already 
low vitality ; and also b}^ favoring farther fibrinous coagula- 
tion within the capillary walls, and in the contiguous cellular 
and glandular structures. 

The external use of ice by means of ice-bags applied to 
the neck, although reputably indorsed, for the preceding 
and other self-evident reasons, can only be potent for evil, 
and is unwarrantable. 

Poultices and fomentations are also advocated by many 
physicians, but in my observation have not proved highly 
beneficial except in laryngeal cases, in which they are of 
great value when carefully applied. The use upon the neck 
of large slices of fat pork is also recommended, but is re- 
garded by the author as not only useless and filthy, but mis- 
chievous. The neck should in all cases be enveloped in sev- 
eral thicknesses of soft, dry flannel. If there be much adenitis- 
and cellulitis, the most efficient application is, in the author's 
estimation, a combination of equal parts of tincture of iodine, 
glycerine, and a fifty per cent, chloral solution, with which 
the swollen and inflamed structures are frequentty to be 
thoroughly painted ; and always to be kept well protected 
from the air by means of several thicknesses of soft, dry 
flannel, as before mentioned. 



92 DIPHTHERIA. 

CHAPTER XVIL 
CONSTITUTIONAL TREATMENT. 

The experience of the medical profession in the treatment 
of all general or constitutional diseases warrants the assump- 
tion that it must be largely addressed to the general system 
through the medium of the blood. If the blood be not itself 
the sole seat of disease, it must at least be the bearer of the 
disease germs, and must be made to carry most remedial 
agents, whether antidotal or recuperative, to the invaded 
structures. Diphtheria has been shown to be a general 
disease of the blood, exhibited only incidentally, although 
with surprising uniformity, b}^ local manifestations. Prima- 
ily it is to be regarded as a blood disease only, manifested 
first, or during the stage of incubation, by very slight de- 
rangements, or none at all. The system is poisoned by the 
infection derived from some person previously diseased, and 
the poison is "working," but is endured without manifesta- 
tions or complaint up to a certain degree, when it is distinctly 
declared by symptoms, systemic and local. This period is 
rather illogically called " the attack." 

The treatment of diphtheria has been and still is, to most 
practitioners, exceedingly miscellaneous and unsettled, as 
well as unsatisfactory. The following quotation expresses 
truthfully the general sentiment of the profession on this 
subject. Prof. Lennox Brown, F. R. C. S., writes as follows: 
" Many general remedies have been suggested, and some have 
been vaunted as specifics, but the most rational and satisfac- 
tory method seems to be that of treating symptoms as they 

arise Those who look on the disease as occurring under 

circumstances similar to those producing erysipelas or phleg- 
monous sore throat ; and especially having regard to its re- 
markable tendenc} r to produce anaemia, as well as its extremely 
asthenic character, will be disposed to give perchloride or 



CONSTITUTIONAL TREATMENT. 93 

other forms of iron ; others who may consider the poison of 
diphtheria allied to that of scarlatina, will prefer to rely 
upon cinchona with acid or ammonia ; other practitioners, 
again, may be more willing to depend upon the sustaining 
properties of strong and easily digested nutriment, with the 
moderate use of diffusible stimulants. Seeing how unsatis- 
factoty the results of drugs are in this disease, it certainly 
does not appear desirable to push nauseous, and often not 
easily assimilated medicines, in a disease so prevalent among 
young children, who in addition to having a natural dislike 
for medicines, experience great pain in attempts at deglu- 
tition." 

Mackenzie says, "There are few cases of diphtheria in 
which systematic feeding does not constitute the most im- 
portant part of the medical treatment." Prof. J. Lewis 
Smith says, "It is remarkable that there is so little agreement 
in the profession in regard to the medicinal treatment of 
diphtheria, since this disease has now been under almost 
constant observation during the last twenty years in the prin- 
cipal cities of this country, and many epidemics have been 
closely observed and reported by intelligent physicians in the 
rural districts." 

In the presence of the prevailing professional sentiment 
regarding the therapeutic treatment of this disease, so 
elegantly and truthfully expressed in the above quota- 
tions, which fairly represent the diversity of opinions, or 
positive antagonisms existing among medical practitoners 
and writers on this subject ; to dissent to the views or prac- 
tice of eminent medical authors is neither discourtesy nor 
professional heterodoxy. On the contrary, this condition 
invites research, observation, experiment; a struggle for new 
light to supplant the confusing darkness ; and imposes on 
physicians an imperative duty to report to their brethren the 
discovery of any new plan of treatment or new remedy, 
which, supported by sufficient experience, and success on 



94 DIPHTHERIA. 

trial, furnishes a basis for a true faith, and a consistent 
uniformity, or at least similarity, in the means employed. 

The writer comes before the medical world with a new book 
not merely containing a rehash of what has been said or 
written before on this subject, (although the writings of 
others have been searched, freely quoted, contrasted, and 
weighed ; and in the department of therapeutics mainly re_ 
jected on account of their want of specific practical value)- 
but he appears in these pages as the herald of a new depart- 
ure, which is not new in the sense of being untried or un- 
proven ; and as the advocate of a specific treatment of the 
membranous diseases by a remed} 7 which has championed its 
way to his full confidence by the exhibition of such remark- 
able power in diphtheria as to have reduced its mortality to 
a percent not greater than that of malarial fever when treated 
with its specific, qninia. It is hardly necessa^ to say, after 
what has been already written, that this remedy is chloral hydrate. 

It is not used to the exclusion of such other rational 
remedial measures as are indicated by the symptoms, nor 
such as are believed to aid its specific action. Before 
detailing the mode of administration and its supposed 
modus operandi, it seems best, in order to a full view of 
the subject in hand, that we should cursorily pass in review 
the remedies in most general use ; that each ma} 7 be, as near- 
ly as possible, assigned its appropriate sphere by the prac- 
titioner ; and also to give to the student a correct but con- 
densed view of the entire literature of the disease. 

Cathartics. The operation of an efficient laxative in diph- 
theria is not open to the objection of Dr. Slade, based upon 
the idea that it increases the asthenia. Quite the reverse is 
the fact if the remedy be properly selected and its effects lim- 
ited within reason. By its operation we not only relieve the 
plethora and the fever, but by promoting the secretion may 
reasonabl} T hope to eliminate from the system some portion of 
the specific virus of the disease. 



CONSTITUTIONAL; TREATMENT. 95 

The weight of authority in this matter is on the side of 
reason, in favor of the administration of a prompt efficient lax- 
ative as early as possible in the disease, unless contraindicated 
by some such conditions as diarrhoea, unusual debility, or ex- 
treme malignancy, all of which must enter into the account 
of the attending physician in adjusting his treatment. Sir 
Wm. Jenner and Dr. Aitkin advise calomel and jalap for this 
purpose, or a calomel and colocynth pill, followed in the in- 
flammator3 T forms of the disease by a saline aperient. My 
practice is to give from five to fifteen grains of calomel, ac- 
cording to age and conditions, combined with an equal or 
greater weight of bicarbonate of soda, and followed in three 
•or four hours, if by that time it have not moved the bowels 
sufficiently, by a draught of Rochelle salt, a portion of castor 
oil, or an enema of tepid salt water, or soap suds. 

Emetics, although of doubtful utility, are often emplo} T ed in 
diphtheria for the purpose of effecting the detachment and 
expulsion of the false membrane, and are thought by some to 
be of especial value when the laiynx is involved in the 
diseased process. If in such cases they prove beneficial, it 
must be mainly by causing maceration of the false membrane 
by the free secretion of mucus about and beneath it, aided by 
the vomitive effort induced for its expulsion. Mucus is not 
known to be a solvent of the exudate, nor is it by any means 
certain that its presence greatly accelerates its separation. It 
is, however, generally abundant in the throat when it is the 
seat of the deposit. A loosened membrane or one but par- 
tially detached by the physiological process, and irritating 
or obstructing the lar}mx and glottis, is not infrequently 
■expelled by the vomiting caused by its presence in such 
localities, and when such a state of the membrane is known 
to exist and does not occasion the necessary vomiting, it is 
reasonable and proper to cause it b} T irritating the fauces 
with a feather or the finger carried far back into the 
throat. 



96 DIPHTHERIA. 

The debilitating effect of antimony and ipecac, especially 
the former, is well known, and their use is therefore not to 
be thought of in states of prostration such as are usually seen 
in diphtheria. Even the exertion of vomiting, in cases of 
great debility, is to be feared, and avoided if possible. 

If in any emergency, the use of an emetic seems imperative, 
the patient should be guarded from harm by being previously 
placed under the influence of an alcoholic stimulant, or a sup- 
porting dose of morphia (one sixteenth to one sixth of a grain), 
or both combined ; and even then it will be necessary to 
select only such emetics as act quickly and briefly. Those 
least objectionable are, doubtless, powdered mustard seed 
in doses of one or two teaspoonsful in a wine-glass of 
tepid water, and the sulphates of zinc and copper. 

The copper salt may be given in doses of from two to ten 
grains, mixed with powdered sugar, every ten or twelve min- 
utes until it acts : the zinc dissolved in tepid water in doses 
often grains for children, to sixty for adults, and may be re- 
peated in five minutes. Bretonnau, for reasons given, pre- 
ferred the copper ; J/R Cormack advises the zinc. Opinions 
differ, and the practitioner has abundant authority for his 
choice. About the only valid reason that can be assigned for 
the administration of an emetic in diphtheria, let it be under- 
stood, is to get rid of the annoyance and danger of detached 
or partly loosened membranes irritating or obstructing the 
larynx. They are not believed to occasion its loosening if 
given before that process is at least partially effected through 
the ordinary process of inflammation. 

The tincture of the perchloride of iron, and quinine are the 
two remedies more generally employed at the present time 
than any others, though upon what principle it is not easy to 
decide. They are variously classed by writers as tonics, re- 
storatives, specifics, recuperatives, and antiseptics, or as be- 
longing to two or more of these classes. 

From the fashion in the medical profession at the present 



CONSTITUTIONAL TREATMENT. 97 

time of prescribing one or both of these valuable remedies in 
every case of diphtheria and in every stage, it is necessarily 
inferred that they are regarded as specifics. They are pre- 
scribed as uniformly in this disease as are any of the known 
specifics in the diseases they are known to arrest. If judged 
in this light, in view of the slightly diminished rate of mortal- 
ity since the times of Bard and Bretonnau, with bleeding, 
mercury and blisters, they must, with these discarded rem- 
edies, be regarded as flat failures. 

Among a respectable minority who regard iron as possess- 
ing no special utility in this disease, West, in his Diseases of 
Children, has the following : " Neither have I found it to 
vindicate in my hands its claims to that special specific virtue 
for which some practitioners have given it credit." Flint, in 
his Practice of Medicine, speaks most decidedly on this sub- 
ject, saying : " The tincture of the chloride of iron does not 
exert a specific influence as some have supposed." 

If it is not as a specific that iron is prescribed, it is probably 
as a restorative tonic. Here, in diphtheria, markedly in its 
early stages, the acknowledged indications for its administra- 
tion are usually noticeably lacking. M. Bretonnau wrote in 
1826 : "At the onset of diphtheria the organic functions and 
those which belong to the life of relation, are so little dis- 
turbed that children who are alread} 7 dangerously affected by 
malignant angina, generally retain their habitual appetite, and 
continue their play" — an observation very applicable to 
numerous cases at the present time. The nutritive fluid is 
not impoverished, as the appetite and digestion are as yet 
but slightly impaired ; neither anaemia nor emaciation being 
manifest, but only such depression of the vital powers as 
results from the toxaemia. The rational indications in this 
condition seem rather to call for nutrients and alcoholics, or 
specifics, to fortify the system against the progressing ravages 
of the disease, or to counteract and eliminate its virus, than 
for iron as a restorative. It is not rendered even probable by 
7 



98 DIPHTHERIA. 

the state of the patient that the blood is suffering from any 
want of iron in the composition, but as before intimated, from 
the effect of a specific poison for which iron is not even 
claimed to be an antidote. This systemic condition calls for 
support till the disease is overcome by the recuperative ener- 
gies and its germs eliminated; or else for specific treatment, 
and iron quite certainly meets neither of these requirements. 

I am permitted to make the following quotation from an 
unpublished thesis of an esteemed medical friend : 

" The tincture of the chloride of iron is by man}'- regarded 
almost if not quite in the light of a specific in diphtheria. 
Its admirers and upholders, aside from considering that it de- 
stroys or neutralizes the specific poison to which the disease is 
due, advocate its use on the ground that it is a tonic, an 
astringent, an appetizer, and an antiseptic. All of these 
qualities, except that of a specific, the remedy under consid- 
eration most unquestionably does possess. Its action as a 
specific is certainly not well supported. As a tonic and re- 
storative, iron is unquestionably one of the best. It is one 
of the great triad of restoratives, quinia and cod-liver oil 
being the other members. But is tonic and restorative 
action required, as a general thing, thus earl} 7 in diphtheria ? 
And when required, is iron the best agent to employ ? The 
patients are generally } T oung and vigorous, often plethoric, 
and tonics are often strongly contraindicated. And when 
required, beef-juice, eggs, milk, cream, egg-nog, and nutrients 
generally, fulfill the indications better than iron. 

" As an astringent, tincture of iron has the same proper- 
ties as Monsell's solution, intensified in degree, and is more 
irritating. In common with astringents as a class, it checks 
secretion by constringing the mucous surfaces with which it 
comes in contact. But in diphtheria the indication is to get 
increased action of the mucous glands, as the restoration of 
the normal secretion facilitates the separation of the pseudo- 
membrane • and astringents are contraindicated. 



CONSTITUTIONAL TREATMENT. 99 

" The mucous glands under the membrane are either acting 
abnormally, or not acting at all. This perversion or suspen- 
sion of their function must be rectified, and the normal secre- 
tion restored if we would imitate our great teacher, Nature, 
and favor the separation of the pseudo-membrane in the 
natural manner. And in the inflamed condition of the 
throat the local application of an irritant is anything but 
beneficial. As an antiseptic it does not rank as high as 
many others that are far less irritating in action. 

" Appetizers are hardly needed in the commencement of 
the malady, and in children, with whom we have most fre- 
quently to deal in treating this disease, the tincture of iron, 
by its disgusting taste, begets a loathing rather than a long- 
ing for food. Its exhibition is pushed in diphtheria ; full 
doses frequently repeated being the rule. But no less an au- 
thority than Pareira says that when swallowed even in medi- 
cinal doses it readily disorders the stomach. Hence it de- 
feats its own object. 

" In diphtheria the fever is often very marked, and there 
is a tendency to fibrinous deposits not only in the throat, but 
in the cavities of the heart, and embolism is not infrequent. 
Iron certainty will not abate the fever, and is not known to 
have any power to arrest membranous, or to prevent or ar- 
rest fibrinous coagulation in the chambers of the heart and 
the blood-vessels, and therefore is not indicated. After the 
high fever has passed away and the vital forces of the patient 
are very low, seems to be a more reasonable time for the 
employment of this remedy. And there are arguments 
against its use even here. In Wood's Materia Medica we 
find the following : Analogy has suggested its employment 
in other adynamic affections, such as diphtheria and pyaemia, 
but its value in these diseases is much more than doubtful. 

" According to Stille, iron is contraindicated in congestion 
and inflammation, which would go to exclude it from our list 
of diphtheritic remedies. 



100 DIPHTHERIA. 

"Iron is generally administered in large and increasing 
doses, from the first to the last visit of the attending physi- 
cian, to adults in doses of 3 ss to 3 i every two or three hours 
diluted with water and glycerine, and to children in propor- 
tionate doses ; or the following to a child of five years : 

3 Tinct. ferri chloridi, 
Potas. chlorat. aa 3 ij, 
Syr. simp. 3 iv, misce. 

A teaspoonful every one or two hours. (Smith.) 

These doses are often considerably increased. If the case 
be malarial or malignaut, quinia and whisky are far more 
rational." 

Quinia may be sometimes required as indicated, but is 
neither known nor supposed by the writer to possess any 
peculiar therapeutical properties that render it any more effi- 
cacious in diphtheria than in any other febrile disease in 
similar conditions. Its great value as a remedy has led too 
many practitioners into its indiscriminate use in the most 
diverse and contradictory conditions, apparently upon no well 
settled therapeutical principle ; but as being the first thing 
to suggest itself as possibly possessing some indefinable 
property to meet almost every emergency, local or general, 
acute or chronic, that may occur in practice. 

The very general administration of quinia in this disease 
can only be accounted for, first, from its being regarded as a 
specific. This deduction seems almost a necessity, as it is 
given, as is iron, early and late in the disease ; when symp- 
toms, are sthenic or asthenic ; adynamic, malignant, or benign ; 
laryngeal, nasal, or faucial ; and with the same uniformity 
with which it is given in intermittents, for which it is an 
acknowledged specific; or second, for its supposed tonic proper- 
ties, in view of which it nw at times be beneficial. Be it 
remarked, however, that no small proportion of the cases of 
diphtheria are characterized for the first twenty-four or forty- 
eight hours by high arterial action and a corresponding 



CONSTITUTIONAL TREATMENT. 101 

increase of temperature, and that the effect of quinia in ordi- 
nary medicinal doses is to increase the heart's action and the 
body heat. It is consequently more rationally prescribed 
in states of great exhaustion and debility. Any means 
which, in these sthenic states, has so direct a stimulating 
effect, cannot be other than hurtful, as the high action is a 
chief agent in consuming or exhausting the vital powers, 
which at this stage should doubtless be conserved by a cau- 
tious lowering of the temperature and calming the circula- 
tion by tepid sponging, or a few doses of aconite or veratrum 
in connection with the chloral treatment. 

Two to four grains of quinia every two or three hours in 
such sthenic states, which is common practice, theoretically 
should be, and doubtless is, pernicious. If given at all in 
such states it should be in anti-pyretic doses of ten grains to 
a child of five years, and twenty or thirty grains to an adult, 
and promptly suspended, if, at most, two or three doses at 
intervals of three hours do not effect the desired reduction in 

body heat and pulse rate Quinine may be given, third, as 

a mere matter of routine, or a blind concession to writers whose 
recommendations are regarded as sufficient warrant for the 
practice. Quinia is a most valuable remedy, as are also 
mercury and atropia, but it does not follow that they should 
be given to all persons in all diseased conditions. Their 
power for good, when indicated, is no less potent for evil when 
contraindicated. What, for example, can be expected from 
such practice as the following, reported, but not sanctioned, 
by Prof. J. L. Smith in the immediate connection with the 
remark " that quinia does not exert any special or peculiar 
action in diphtheria, and is beneficial in the same way and no 
further than in other acute infectious diseases, is, I think, 
generally admitted by the profession ; for large doses do not 
exert that controlling effect, which we would expect from a 
specific, as is shown by cases like the following, which are not 
infrequent during severe epidemics : 



102 DIPHTHERIA. 

"C. aged four years, male, was examined by me m con- 
sultation, on February 10th, 1876. I learned that he had 
apparently contracted diphtheria from the escape of sewer 
gas through a defective trap in the little room where he slept, 
and that the disease began after middaj^ on February 6th, 
with fever ; at 10 P. M. of the same day, when visited by the 
family physician, the temperature was 103°, and the fauces were 
red, but without an}- pseudo-membrane. Four grains of quinia 
were ordered to be given every two hours, and ten drops of 
the tincture of the chloride of iron, with two grains of the 
chlorate of potassa, to be given three times hourly. On the 
7th the exudation covered both tonsils and the half arches j 
temperature 102^-° ; evening, temperature 100° ; pulse 128. 
8th, is playful ; pulse 100 ; has slight swelling of the cervi- 
cal glands; evening, some extension upward of the pseudo- 
membrane ; has vomiting. 9th, Pulse 144 ; vomits often. 
10th, at 3 P. M. began to grow worse ; phanynx and nostrils 
covered with exudation." 

Forty-eight grains of quinia and one and one half ounces 
of the tincture of the chloride of iron a day for four con- 
secutive days to a child of four years, or a total of 198 
grains of the former and six ounces of the latter ! ! What 
physician will wonder that, with the recuperative powers so 
weighed down and embarassed with such an amount of 
nauseous drugs, the little one should grow worse day b} 7- day, 
should vomit on the third da}', and die on the fourth of 
"toxsemia ?" 

"Drugs are medicines when they cure, 
But poisons when to death they lure." 

Prof. Smith in commenting upon this case sa}'s: 
"It was impossible, at the time of my visit to obtain any 
of the patient's urine for examination, and death occured a 
few hours afterward from the toxaemia. Forty-eight grains of 
quinia administered dail}-, from the first day, had no appreci- 
able effect in sta} T ing the fatal progress of the malady, had 



CONSTITUTIONAL TREATMENT. 103 

no such effect as would be likely to follow, were its action 
specific or antidotal. But there are two advantages from the 
quinia treatment, which explain the confidence reposed in it 
by the profession : 1st. It has an antipyretic effect in doses of 
from three to five, or more, grains. 2d. In moderate doses it 
is one of the most reliable tonics. But high febrile move- 
ment, requiring an antipyretic, I have seldom observed in 
diphtheria, except in the first forty-eight hours ; and if, during 
this time, the febrile movement be such that an antip} T retic 
Is required, quinia in the large doses is preferable, in my 
opinion, to any other rerned}\ In its subsequent use, namely, 
us a tonic, two grains may be administered every two to four 
hours. But other bitter mixtures, which have been found to 
be the most useful tonics in general practice, perhaps would 
meet the indication nearly or quite as well." 

In the history of medicine no remedy has been so much 
abused, or brought into such undeserved discredit by its 
advocates, as quinia ; if only we except mercur} 7 and blood- 
letting, the panaceas of the age just past. "It will certainly 
cure malarial intermittents, and hence, as they are febrile 
diseases, it is probably remedial in all other fevers," is a 
process of reasoning that answered well enough for the facile 
quack who, after failing to cure his ague by lobelia et al, 
was forced by suffering, against what he thought his better 
judgment, to resort to quinia, and being promptly cured, became 
so strongly converted that he not only prescribed it for every 
disease, but adopted it as an article of diet, and daily 
sprinkled with it his potato and bread-and-butter. Such a 
philosophy is quite too prevalent, as is easy to see, in the 
practice of some regular physicians. An army phj-sician 
once prescribed quinine for a subordinate afflicted only with a 
sore toe. Such aimless, senseless, routine practice may not 
often endanger the patient, but is certainly a reproach and 
disgrace to physicians so afflicted with mental or moral 
stupidity. 



104 DIPHTHERIA. 

As a general tonic the claims of quinia, although strongly 
contested, are for the present conceded ; and hence we regard 
it as remedial in states incident to diphtheria, but know of 
nothing entitling it to rank here as a specific. "As a rule, 
however," says Mackenzie, "quinia is more useful after the 
more serious s}'mptoms have abated, when it may be very 
suitably combined with iron and a mineral acid. Morphia 
and chloral are occasional!} 7 necessary to combat continued 
sleeplessness, and to ward off the exhaustion which is its 
invariable consequence." 

Chlorate of Potash. This salt, usually classified among 
diuretics, has since its introduction by Hunt in 1847 for the 
treatment of cancrum oris, achieved a cosmopolitan reputa- 
tion in the treatment of ulcerative diseases of the mouth and 
throat. Many practitioners hold that it, as well as chloral, 
possesses aplastic powers, or the property of checking the 
formation of an exudation, and it is doubtless more generally 
prescribed in croup and diphtheria than almost any other 
remedy. West is said to have been the first to formulate its 
use in membranous stomatitis, which occasionally exhibits 
pseudo-membranous patches on the gums and buccal surfaces. 
We do not, however, class ulcerative stomatitis among the 
membranous diseases. Subsequent observers have not only 
confirmed the favorable reports of Dr. West, but have con- 
ferred upon this remedy the character of a specific in the 
treatment of this hitherto refractory affection. Its mode of 
action is not understood, but its almost universal efficacy in 
ulcerative stomatitis is one of the few established facts in 
clinical medicine. 

Having achieved such a reputation, how naturally comes 
the suggestion to test its utility in other diseases more 
uniformly attended with membranous exudation. Bluche is 
supposed to have been the first to try its efficacy in diph- 
theria. The results were not as emphatic as in ulcerative 
stomatitis, but were encouraging. "Since then, cases have 



CONSTITUTIONAL TREATMENT. 105 

multiplied in all quarters, and the facts authorize us to con- 
sider chlorate of potash, as a remedj^, perhaps not sure, but 
at least able to render some service in this grave disease. 
But in this respect we must make an observation. Croupous 
angina (diphtheria) has ver} T various degrees of gravity, 
according as it appears sporadically or as an epidemic, and it 
would be supremely irrational to draw conclusions from thera- 
peutic experience in cases so unlike. If it is true that in 
malignant angina, especially when epidemic, chlorate of 
potassium generally fails, as most treatment does fail, it can- 
not be denied that the same remedy has procured success in 
quite different circumstances, that is, when croupous angina 
presented chances of curability. In this respect the obser- 
vations made at the children's hospital, or published by a 
large number of physicians at Paris and in the country, 
scarcely permit a doubt. We will say, then, with Isambert, 
that the usefulness of chlorate of potassium, in cases of 
medium intensity, seems to us proved, not only by a real and 
-definite success, but by its special and almost elective action 
upon the pharyngeal mucous membrane, identical with that 
which is observed in membranous stomatitis. The return of 
the rose red color, the fall of the false membranes, the low- 
ered pulse, are often in a space of time which is sensibly the 
same in both cases. This observer adds that cauterization, 
employed concurrently, does not seem to him to hasten the 
action of the chlorate at all, but sometimes to impede it." 
(Trousseau.) 

In as much as clinical facts are more to be trusted than the 
most elaborate theories without such confirmation, and as like 
testimony to the utility of this medicine in diphtheria is borne 
by nearly all observers, everywhere, it must be accorded a place 
among the tried and useful remedies in diphtheria. Its dose 
is from two to ten grains, in aqueous solution, every hour, 
and should be given in conjunction with from one to five 
grains of chloral hydrate. (Form. Nos. 22 & 23 at end of vol.) 



106 



DIPHTHERIA. 



The internal treatment of Dr. J. L. Smith, which is very 
generally followed by American physicians, is the administra- 
tion in alternation of formulae Nos. 19 & 20, which he de- 
clares he has found to constitute the most satisfactory inter- 
nal treatment. He also advises citrate of iron and ammonia, 
alone, or in combination with carbonate of ammonia, in two 
grain doses, dissolved in simple syrup, in place of the latter, 
when the inflammation of the fauces has considerably abated, 
or is moderate. As a disinfectant to be applied within the 
nostrils, he advises carbolic acid, gtt. xxiv, glycerine § ij, 
and water 3 vi ; to be injected every four hours. Also lime- 
water spray in laryngeal cases. 

Mercury was considered by Bretonneau and others as the 
most important of remedies in the constitutional treatment 
of diphtheria, and Dr. Bard wrote "Although I consider 
mercury the basis of the cure, especially in the begining di- 
sease, I do not by any means intend to condemn or omit the 
use of proper alexipharmics and antiseptics." 

Very few practitioners of the present time prescribe this 
agent in any other wa}^ than as a laxative in the early stages 
of the disease. Its specific effects are now known to increase 
the asthenia and adenitis, without any compensatory effect to 
neutralize or to eliminate the specific poison ; hence mercury 
is practically and deservedly expunged from the list of anti- 
diphtheritic remedies. 

Sulphide of potassium, regarded by Swiss physicians as a 
valuable specific, probably does more harm than good, and is 
only mentioned to be condemned. 

Bromine and the bromides hafe also failed to vindicate the 
expectations of their advocates, and are practically abandoned 
except in lar3 T ngeal cases. 

Carbolic and salicylic acids, and the sulphites have been 
vaunted since the promulgation of the bacterian theory, as 
constitutional as well as local remedies of great value for the 
destruction of those minute low organisms of which Eberth 



CONSTITUTIONAL TREATMENT. 107 

has said : " Without micrococci there can be no diphtheria." 
These remedies, or some of them, doubtless do possess in a high 
degree, bactericide properties; and, were the theory true, 
would be genuine specifics for diphtheria, at first locally, and 
afterward systemically, through the medium of the blood. 
These remedies I have formerly often used very early in the- 
disease, both locally by careful application to the entire in- 
flamed faucial surfaces ; and internally, either at the same time 
or subsequently, without any apparent modification of the pro- 
gress of the disease. Other observers have had similar ex- 
perience of their inutility. J. Lewis Smith expresses himself 
upon this point as follows : 

" But experience, if sufficiently extensive, is the safe guide- 
in therapeutics, and, according to my observations, internal 
antiseptic measures have not seemed to exert any marked 
controlling effect on the course of diphtheria." 

As bearing upon this subject he refers to a case of a four 
years old child, who took " Almost from the beginning of the 
sickness, a mixture of potassa and iron on the first hour, two 
grains of quinine on the second hour, and three grains of 
salic3'lic acid on the third hour, and this treatment was con- 
tinued night and day, and yet this child, having from the first 
taken sixteen grains of quinine, twenty -four of salicylic acid,, 
beside the potash and iron daily, died after eight days with 
profound blood poisoning, having had many extravasations of 
blood." 

Mackenzie says : " I have not employed carbolic acid my- 
self as an internal remedy, but the sulphocarbolates as rec- 
ommended by Dr. Sansom have often proved of service in 
my hands, in the secondary poisoning of diphtheria. In the 
primary septicaemia, these remedies have appeared to me quite 
useless." (Form. No. 26.) 

Balsam of copaiba and cubebs, so well known for their action 
on the mucous membranes, have been used both as specifics- 
and as expectorants in diphtheria, and are well spoken of by 



108 DIPHTHERIA. 

veiy reputable observers. Mackenzie says : he Las found 
distinct benefit in catarrhal cases from perles of copaiba, 
but is of the opinion that neither copaiba nor cubebs can lay 
claim to anything like a certain and specific action. Dr. Be- 
verry Robinson, one of the physicians of Charity Hospital, 
New York, following the teachings of Trideau, is an advocate 
of the treatment by freshly powdered cubebs, {American Jour- 
nal of Medical Sciences, July, 1876.) Its action he considers 
to be that of a stimulant to the mucous surfaces, both by con- 
tact, and by elimination through the respiratory mucous mem- 
brane and the kidne}-s. To a child of five years he gives gr. x 
in sweetened water every two hours. 

Senega alone or in combination with carbonate of ammonia, 
has also been found useful, probably by promoting secretion 
by the mucous and salivary glands. B} T increased secretion 
beneath the false membrane its separation imiy possibly be 
promoted, and the pharjmgeal congestion in some degree 
relieved. 

Of expectorants it has been said no other is equal in effica- 
<jy in diphtheria to pilocarpin. Dr. Guttman, of Cronstadt, 
has recently treated sixty-six cases with this remedy, with 
most satisfactory results. " Fifteen of these exhibited the 
worst s}'mptoms of diphtheria, of which at least two-thirds 
according to previous experience, would have died ; thirty- 
three bad cases had extensive membrane, the .others slight. 
He gave pilocarpin to all, and in the first cases associated 
this treatment with quinine and gargles only, they recovered 
in periods, as a rule, varying from twenty-four hours to three 
days ; of the fifteen worst cases, two recovered in nine and 
eleven days, the rest in two to five days. All patients who 
came early under treatment, while the pseudo-membrane was 
still loosely adherent, without exception were cured in twen- 
ty-four hours. The doubt that these cases were not truly 
diphtheritic is not to be raised, since they were examined 
"with the utmost care, and, in the worst cases, the contagion 



CONSTITUTIONAL TREATMENT. 109 

could be distinctly traced. Under the action of pilocarpin 
not only were the membranes and infiltration dissolved in the 
salivary flow, but also the violent inflammatory condition 
yielded to its influence, the deeply reddened, dry mucous 
membrane soon became moist, pale red, and in every respect 
of normal appearance." {Boston Medical and Surgical Journal, 
Oct. 6th, 1881.) 

For his mode of administering the remedy, see formulae 
27 and 28, each dose to be followed by " a small amount of 
generous wine." Others who have used this remedy in a 
similar manner report favorably of its effects. 

An eminent American author (Flint) has asked the following 
simple question : " Is there any known specific remedy for this 
disease ? " and replies that " the question must be answered 
negatively, unless we give credence to the doctrine advanced 
by Dr. E. W. Chapman, namely, that the special morbid con- 
dition of the blood is antagonized by alcohol. Dr. Chapman 
claims that by the early administration of alcohol, as freely as 
it is tolerated without alcoholic excitation, in conjunction 
with quinia, the disease is curable. He bases this doctrine 
on the results of a pretty large clinical experience. He em- 
ploys alcohol, not as a sustaining remedy, but as an antidote, 
comparing its efficacy to that which it has in cases of ven- 
omous snake bites. The claim in behalf of this method of 
treatment is not irrational, and it should be tried sufficiently 
to test its value. To the usefulness of alcohol in the treat- 
ment of this disease the author (Flint) can add his testimony 
to that of others. The tolerance of alcoholics is, in some 
cases, notably increased by the disease. It should be given 
to the extent to which it is tolerated without any manifesta- 
tion of its toxical effects. The novelty of Chapman's doc- 
trine is that its utility depends on its antidotal effect, and 
that, therefore, the earlier in the disease it is given, it is bet- 
ter, not waiting for evidence of failure of the vital powers. 
A French author, M. Sanne, considers alcohol the most effec- 



110 DIPHTHERIA. 

live of antiseptics which are administered internally, and 
that it is indicated in proportion to the intensity of the infec- 
tion." 

It is believed by the writer that the experience of the med- 
ical profession thus far, fails to support the claims set up 
for alcoholics to antidotal or specific virtues in diphtheria, 
and that the}?- are only of value as in other asthenic diseases 
or exhausted states of the bodily powers. Under such con- 
ditions of prostration as often occur in diphtheria their ex- 
hibition is imperative, but not more so than if the cause be 
typhoid fever or any other exhausting disease. The sj^mp- 
toms believed to indicate, and which should govern their use, 
are given elsewhere in this treatise, and are, therefore, dis- 
missed for the present. 

Dr. Aitkin answers the question by saying : " We have no 
specific treatment which can cure the disease or eliminate the 
poison," and Dr. Hartshorne declares that "no specific 
remedy having been discovered, we must be governed in our 
tentative treatment b}? - our idea of its nature, while conclud- 
ing upon its therapeutics finally through experience. Noth- 
ing, it must be confessed, is ver}^ satisfactory as yet in the 
management of bad cases." Jacobi expresses himself as fol- 
lows : "I know of no specifics for diphtheria, and recommend 
no uniform treatment for all persons and all cases." 

These quotations no doubt truthfully and lucidly express 
the prevailing convictions of the medical profession ; and yet 
are logical intimations of the belief that a specific may exist, 
and a hope that careful observation and research may reveal 
it. It is certainly no less probable that such may exist for 
this particular form of blood-poisoning than for such others 
as the malarial and sj'philitic. Then, the continued trial of 
new remedies, indicating unrest and dissatisfaction with the 
result of every therapeutical resource hitherto applied; are 
eloquent and logical, even if only inferential proofs of a be- 
lief in the probable existence of some such remedy. 



CHLORAL TREATMENT. Ill 

The result of the writer's experience and convictions is 
that he can truthfully reverse the negative reply to Prof. 
Flint's question, " Is there any known specific remedy for this 
disease ? " and confidently intrust his affirmation to the severe 
scrutiny and crucial tests to which such a claim must be sub- 
jectad by the medical world. 



CHLORAL TREATMENT. 

To set forth the claims of chloral hydrate to specific virtue 
in the treatment of diphtheria, is the main object of this 
monograph, and the sole excuse for adding another to the 
long list of books on this subject. Frequent references have 
already been made to this treatment, especially in the chap- 
ter on local treatment. A farther canvas of the claims of 
chloral as a constitutional remedy will necessitate more or 
less of repetition, for which the forbearance of the reader is 
solicited. 

The merit of the discovery of chloral, in 1832, is accorded 
to Baron Liebig, and its production and composition deter- 
mined by him and Dumas. The remarkable anti-septic, dis- 
infectant, and deodorizing powers of this invaluable remedy 
might reasonably be inferred from the materials employed in 
its manufacture, viz ; dry chlorine gas and absolute alcohol. 
" In the experience of Dr. Squibb, ninety-two pounds of alco- 
hol required the continuous generation of chlorine gas for 
twenty-eight days, using about 1^ tons of mixture of man- 
ganese binoxide and common salt, and yielded about 160 
pounds of crude chloral." (National Dispensatory.) 

Chloral hydrate is not, however, merely condensed and 
solidified chlorine gas, although it possesses manj r qualities 
in common with both it and alcohol ; but is a new substance, 
having qualities not known to exist in either, or in both com- 
bined in any other way. Jn its power to allay pain and pro- 



112 DIPHTHERIA. 

duce sleep it may be said to somewhat resemble opium. Its 
control of pain is less positive, and the sleep induced more 
like natural sleep. It seldom produces the untoward effects 
of opium, such as nausea, dryness of the fauces, constipation, 
anorexia, dysuria, headache and giddiness or malaise. On 
the contrary it is a valuable remedy in nearly all these states. 
Its efficacy is especially exhibited in exhausted and debili- 
tated conditions ; as from overtaxing the brain by prolonged 
mental application or emotional excitement ; or the debility 
occasioned by acute disorders ; and also in various nervous 
diseases caused by anaemia or exhaustion ; in puerperal 
convulsions, mania, chorea, delirium tremens, and tetanus in 
advanced stages. 

Its sensible effects, when taken by an adult in doses of 15 
to 30 grains, are exhibited usually in from five to ten minutes, 
by a feeling akin to mild intoxication, accompanied almost 
from the first by a desire for quiet repose. The face is a lit- 
tle flushed, and the frequency of respiration and the pulse- 
rate somewhat diminished. The sleep induced is generally 
natural and refreshing. Its anti-pyretic effects, in cases of 
exalted temperature, are marked, while its sedation of cardiac 
excitement and irregularity is nearly as noticeable as its calm- 
ative effect upon the brain and nervous system. The stom- 
ach, too, is quieted by its operation, nausea diminished, and 
the toleration of food and medicine improved. These are a 
few of the better known constitutional effects of chloral 
hydrate. 

Besides its topical virtues in diphtheria (see chap. XVI.) it 
is highly esteemed as an antiseptic dressing in surgery and 
in the treatment of various local and skin diseases. Few 
remedies of its years are so honored and esteemed by intelli- 
gent observing physicians. 

Its power to prevent putrefaction and to destroy or prevent 
putrid emanations is well known, and has led to its employe 
ment for the preservation and deodorization of pathological 



CHLORAL TREATMENT. 113 

specimens and bodies for dissection. Its power also to disin- 
tegrate, or in some manner to destro} T , the diphtheritic false 
membrane during its vital connection, has been so often ob- 
served by the writer as to preclude doubt, and is as strongly 
affirmed by other observers. (See local treatment^ 

Diphtheria, in the opinion of the author, is never primary 
in any locality; its local lesions are only the visible manifesta- 
tions of the destructive effect upon the blood of the invisible 
intangible miasm traversing its channels, unbalancing its 
equilibrium, and destroying its vital and nutritive properties, 
as shown by increasing debility, with corresponding increase 
of the infiltration of the glandular and other -tissues with 
plastic material that may also occasion coagulation in the 
cavities of the heart, with fatal results. All this infiltrated, 
exuded, or coagulated plastic matter, wherever it exists, is 
abstracted from the blood. 

In suddenly fatal cases, the decomposed condition of the 
blood indicates so violent an action of the toxic agent that 
the blood was immediately so changed in its properties as to 
render it incapable of coagulation and of supporting life. 
In such cases it is obvious that no treatment can be of any 
avail. 

What is chiefly required of a remedy in diphtheria is, 
then, so to act upon the blood, or the specific virus in it, as 
to correct its constantly evinced tendency to coagulation and 
loss of its fibrin. In the rapidly fatal cases noticed, its 
coagulating power (which is what is usually meant when we 
speak of its vital properties) is immediately destroyed, and 
restoration placed beyond the reach of medicine. 

Has chloral any such power over the tendency of tiving 
blood to coagulation ? 

Blood within its natural channels in health shows no such 

tendency ; when withdrawn and exposed to the air, and in 

this way deprived of its vitality, coagulation speedily ensues. 

If an ounce of healthy human blood, as it flows from an open* 

8 



114 DIPHTHERIA. 

vein, be caught in a wine glass or vial containing one-fourth 
of an ounce of a ten per-cent solution of chloral hydrate of 
the same temperature as the blood, and stirred sufficiently to 
intermix the two, no proper coagulation will afterward occur. 
If the vial be corked no apparent change in color or consis- 
tency occurs thereafter. In appearance it is like carmine ink, 
and flows from the pen as freely, making a bright red mark 
like fresh arterial blood. 

This action of chloral upon human blood may be called 
specific or antiseptic, or by the votaries of the bacterian 
theory it might be called bactericidal, as it has been shown to 
be fatal to these low organisms. To whatever class it may 
be assigned, or whatever be the rationale of its operation, the 
fact is, in my mind, well established, that it exerts a similar 
influence upon the living blood in the body. Prof. Bartholow 
makes the following pertinent and suggestive remark as to 
the therapeutical properties of this remedy. "Besides its 
powers to allay the spasms (in croup) it is one of the few re- 
medies which possess the property to check the formation of 
an exudation." He is here discussing the systemic treatment 
of croup, and hence must necessarily refer to the effects of 
chloral upon the blood, bj r virtue of which effects it limits cr 
arrests the tendency to local exudation within the larynx. 
Upon this point this erudite writer speaks as one possessed of 
positive convictions, if not positive knowledge of the fact 
affirmed, namely, it is one of the few remedies known to possess 
the property to check the formation of an exudation. It checks 
this tendency, then, of necessity, by correcting the cryscrasia 
in the blood ; or, in other words, counteracts or antagonizes 
the abnormal tendency to separation, as well as to coagulation 
of its fibrinous elements. 

Prof. Bartholow is an acknowledged authority in therapeu- 
tics, and we cordially accept his teaching on this subject, as 
it confirms our own convictions long since expressed, and now 
confirmed by a very large experience. 



CHLORAL TREATMENT. 115 

In no other disease is the tendency to membranous exuda- 
tion so strong and so general as in diphtheria. As before 
stated, it is likely to attack and complicate any abrasion of 
the common integument, or irritated portion of the mucous 
membrane ; and in most cases of the disease the thick- 
ness and extent of the membrane are considered the index to 
the proportionate violence of the disease. The disease not 
being primary in any locality, and uniformly the result of 
a specific poison in the blood, rapidly destroying its integrity 
and life, it is apparent that the indications for treatment 
would not be met if limited to the indispensable resources of 
the kitchen, no matter how systematically administered ; nor 
by merely tentative treatment. A remedy is needed more 
rapid in action than the destroying virus, and potent enough 
to limit its ravages or to antidote its toxic agency. 

The effects of chloral in solution follow quickty its introduc- 
tion into the stomach, from which it is almost instantly ab- 
sorbed, and appears in the blood in its identity, and not, as 
formerly taught, changed into chloroform. Its specific effects 
upon the blood are, therefore, speecly, and no doubt are also 
in proportion to the amount taken up. The amount tolerated 
and necessary to its best effects is to be judged by the degree 
of somnolence induced, which should never be profound or 
comatose, but mild and constant, and continued only till its 
office is performed, generally till the disappearance of the 
membranous exudate. 

The conservative character of the effects produced are to 
be judged by its effects on blood freshly drawn ; and its 
further specific effects by the deductions of experience. 

Up to the latter part of 1875 I treated diphtheria as others 
did and many still do, mainly with iron and quinine, and my 
losses tallied with theirs, being from 25 per cent, to 33^- per 
cent., which the records of mortality show to be its present 
rate under ordinary treatment. To say I had become dis- 
gusted by what is called the intractable nature of the disease, 



116 EIPHTHERIA. 

and its fearful fatalit}", is too feeble language to express my 
feelings. I wished most earnestly that I could be excused 
from ever seeing another case, and lost all confidence in the 
modes of treatment employed, and determined to try some 
other. I am still in very great doubt, as are also many 
others, whether there is not more harm than benefit resulting 
from the drugs usually employed. 

The astringent preparations, of iron, for example, if taken 
into the blood, must increase its tendency to coagulate. 
Chloral preserves its fluidity, and thus limits or prevents 
fibrinous separation and exudation, and diminishes greatly the 
danger of extension of the exudate into the larynx and nares ; 
indeed, so great is its power of preserving the fluidity of the 
blood, that the vessels of anatomical specimens injected with 
it by Dr. Keen, were found after several months to contain 
semi-fluid blood, instead of the dirty pasty mass usual. 

Iron is apt to derange the digestion, according to Pareira, 
whose views are confirmed by common experience ; and to 
create disgust and nausea, rather than to promote appetite. 
Chloral, instead of interfering with the digestive function, 
alias's nausea, and thus promotes appetite. 

Iron raises the arterial tension and the temperature, hence 
increases fever. Chloral diminishes the arterial tension and 
efficiently lowers the temperature in febrile states, and di- 
minishes the force and frequency of the pulse. 

Iron increases nervous irritability, while chloral allays it. 
Iron both constringes and irritates the mucous surfaces of the 
fauces, thus diminishing local secretion. Solutions of chloral, 
passing over the inflamed and irritated surfaces, disinfect 
them, and both by its local and constitutional effects favors 
healthy secretion. 

Under ferruginous treatment, the opiates required to obtain 
the needful rest often materially interfere with the normal se- 
cretions ; under chloral, abundant natural refreshing sleep is 
obtained without the vital functions being in any way inter- 



CHLORAL TREATMENT. 117 

fered with, or secretion arrested ; hence albuminuria is ren- 
dered less frequent. 

Iron manifests no particular effect on the toxaemia, while 
chloral, by antagonizing the specific poison, diminishes the 
toxaemia and consequent prostration, and renders paralytic 
sequelae less frequent. . . . Chloral is by many writers and prac- 
titioners regarded an unsafe remedy in debilitated states, in 
which we have shown it is specially beneficial, from fear of its 
paralyzing effects upon the heart. It is yet to be proven that 
pure chloral in medicinal doses is a depressant ; it is more 
easily proven to be a conservator of nervous and muscular 
power by its sedation of nervous excitement, and the refresh- 
ment which results from the repose of quiet sleep, induced by 
its use. Its effects upon the pulse and temperature cannot 
come of induced debility, for the reason that no debility re- 
sults from its use ; which fact is apparent to the dullest per- 
ception ; as it occasions no delirium, no pallor, no blueness 
of the skin, no muscular tremor, nor unsteady action of the 
heart, no sighing respiration, no clammy perspiration, nor any 
other symptom of resulting weakness or paralysis. On the 
contrary the mind is calmed ; pallor diminished b}^ equaliza- 
tion of the circulation ; the tremors even of dipsomania calmed ; 
the gait is steadied ; the pulse is rendered soft and full ; the 
secretions are not arrested, but promoted, and some, notably 
of the mucous and salivary glands, are increased. Quite 
probably chloral will repeat the history of digitalis, which but 
recentty was thought by all writers to be only a substitute for 
the lancet, and to reduce the action of the heart onl} T by 
weakening it ; but has now become the standard tonic in af- 
fections of this organ. No increased debility of the heart or 
any other organ ever results from the proper medicinal use 
of chloral hydrate. Nine grammes (nearly 140 grains) were 
given without harm by Laseque to produce sleep in a patient 
suffering from rheumatismal meningitis, in which belladonna, 
quinia, and other remedies, had failed. Sleep ensued, and the 



118 DIPHTHERIA. 

patient recovered. (Trousseau.) Several hundred grains, in 
doses of from twenty to sixty grains, are frequently given by 
the best phj^sicians, in a few hours, in diseases of great debil- 
ity, as puerperal eclampsia, puerperal mania, &c, not only 
without harm, but with the happiest results. 

Trousseau advises a first dose of 4 grammes (gr. 60) in puer- 
peral eclampsia, to be followed by fresh doses of one gramme 
as soon as the action becomes feeble. Yerneuil advises chloral 
in large doses, and to the extent of 8 to 12 grammes dail}', in 
traumatic tetanus. Trousseau reports fourteen cases of slow 
tetanus, treated with one and one-half to three drachms of 
chloral dail} 7 , and continued from twenty-four to sixty da}'S, 
with eleven cures ; a better showing than can be claimed for 
any other treatment. In none of these cases is debilitj" claim- 
ed or proven to be a contraindication to or result of its use. 
But, were the results of such extreme doses less favorable, or 
even fatal, they could not with any sense be claimed to prove 
that ordinary medicinial doses, continued for a few daj-s, were 
dangerous. Atropia, strychnia, and arsenic, are given in me- 
dicinal doses with impunity and benefit for long periods, 
although it is certainly known that they are deadly poisons 
when administered in too large doses. Even gluttonous 
meals of wholesome food are sometimes fatal, yet nobody 
would be so senseless as to base upon such occurrences an 
argument against rational eating. No more would the evils 
resulting from the abuse of chloral, or from an idiosyncracy, 
militate against its legitimate use in disease. 
• The treatment of diphtheria with chloral hydrate as a chief, 
or I might say as a specific remedy, was first employed and 
advocated by the writer in 1875. Since that time he has em- 
ployed it in more than five hundred cases of well defined 
diphtheria, with a mortality of less than two per cent. Like 
other well attested specifics for other diseases, the earlier in 
the disease the administration is commenced in any case, the 
better; for, as a rule, the toxaemia is rapidly progressive, and, 



CHLORAL TREATMENT. 119 

beyond a certain limit, will overwhelm the vital powers, and 
defy any treatment. 

Chloral is advised in all cases, (see formulae 22, 23 and 24) 
in the place of the irrational iron and quinine mixtures in 
general use, and is given in small doses to the extent of 
inducing a quiet somnolent state. A moderate hj-pnotic 
effect is, in my experience, essential to the best results, as at 
this point, if not before, the temperature and pulse rate are 
reduced, and worry, headache, and nausea disappear. We 
know, too, by this effect, that the remedy has been absorbed 
into the blood in sufficient quantit} 7 to produce upon it spe- 
cific effects. 

Occasionally it is found best to begin treatment with a 
much larger dose in order to reduce the temperature and 
pulse, and to obtain a night of repose, as in the following 
case. Oct. 27th, 1881, Mrs. H., aged thirt} T -five years, and in 
ordinary health, whilst away from home on a social visit, ob- 
served in the early part of the da}' that swallowing caused 
acute pricking pain, and soon after an attending sense of 
fulness and soreness. The preceding night her sleep had 
been interrupted and unrefreshing. As the day advanced, 
headache and backache came on, followed, after a hearty 
dinner, lay nausea and vomiting, with violent pains in 
the head, neck and throat, with sensations of violent 
general sickness, and severe chills alternating with brief 
paroxysms of high fever. She was conve}-ed home late 
in the afternoon. At 8 p. m. she was visited and the pre- 
ceding history of the attack elicited. The pulse was now 
115 and bounding; temperature 104r|-° ; eyes suffused ; skin 
hot ; tongue moderate^ coated and dry, and purplish red 
in the centre ; nostrils stuffed and violenth 7 congested ; de- 
glutition difficult and painful ; tonsils, uvula and velum 
swollen, with patches of false membrane upon both tonsils ; 
submaxillary and cervical glands swollen and tender ; bow- 
els constipated. Ordered twenty grains each of soda bicarb. 



120 DIPHTHERIA. 

and calomel, to be taken immediately, and followed at 9 
o'clock bj r I£ Chloral hyd. 3 ss, tr. opii deod. gtt. xv, in half an 
ounce of well sweetened water. The throat to be covered 
with a light linseed poultice, and enveloped in soft flannel, 
and the patient to be allowed to rest for the night without 
further medication. 28th, A. m. — Patient had quiet sleep 
during the night, and this morning two fecal dejections. 
Pulse 84, temperature 99°, tongue moist ; some increase in 
exudation, but less faucial. and nasal congestion ; glands of 
neck still swollen, but less tender. Ordered formula No. 22, 
which with a few slight variations was kept up till Novem- 
ber 2d, when the patient was discharged — cured. After the 
night of the 27th, only dry soft flannels were applied 
externally. 

To a child of five years suffering from a moderately severe 
attack of diphtheria, about thirt} T -two grains of chloral hy- 
drate in twent}'-four hours is the usual quantity administered ; 
in combination with an equal amount of chlorate of potash, 
(Form. No. 23) in syrup and water, and administered in 
drachm doses hourly, except during refreshing sleep. The 
quantity should be increased or diminished in proportion to 
the age of the patient, and according to the exigencies of the 
case ; and if marked somnolence be produced, the frequency 
of administration may be somewhat diminished. The ad- 
ministration is uniformly commenced on the first visit, and 
continued till all exudation has disappeared, and longer, in 
diminished quantity, if the toxaemia or local manifestations 
demand it. 

Should the irritability of the stomach seem to preclude the 
present administration of chloral, it will generally be found 
to be controlled by the laxative before mentioned, and if 
necessary, recourse may be had to such other means as are 
generally emplo3~ed to allay nausea. 

Should the febrile manifestations be very marked, a few 
doses of aconite or veratrum may be administered, but in 



NASAL DIPHTHERIA. 121 

most cases the chloral is the only febrifuge required. If, on 
the contrary, malignant or typhoid symptoms are manifested, 
the administration of pure rye or bourbon whisky, or pure 
brand} T , in milk punch or egg-nog, or other eligible forms, is 
indicated, and if well borne, continued in increasing quanti- 
ties, up to the limit of toleration. While administering alco- 
holics, the chloral mixture should generally be continued in 
alternation. 

Experience has shown that the excessive use of alcohol is 
seldom required in connection with the chloral treatment ; if, 
however, it be indicated, as above, its use is emphatically en- 
dorsed. 

If headache or pharyngeal or other pain be complained of, 
these generally subside within a few hours after the com- 
mencement of the chloral treatment. 

The mouth and faucial and phar} T ngeal surfaces are effect- 
ually disinfected by each dose, and as the local action of 
the remedy is also desirable, no drink should be permitted for 
several minutes afterward. In most cases no other local treat- 
ment is required. For other local treatment see chapter XYI. 

The patient should be allowed abundance of agreeable 
refreshing, and nutritious drinks, as cold water, milk, lemon- 
ade, barley or rice water, toast coffee, beef tea, or milk and 
raw egg. For further directions with regard to nourishment, 
see chapter XIY. 



CHAPTER XVIII. 
NASAL DIPHTHERIA. 

Nasal diphtheria is much more frequent in some epidemics 
than in others, and is so designated solely on account of the 
implication of the nasal passages, either as the primary seat 
of the local affection, or as the consequence of its extension 
to the nares from the pharynx. 



122 DIPHTHERIA. 

The nares are, however, but seldom at the first invaded by 
the diphtheritic inflammation, or the original seat of the mem- 
branous exudation. The affection is generally secondary, the 
result of the extension of like processes from the pha^nx. 
The disease, or, rather, the complication, is usually at first 
shown by a yellowish or brownish ichorous discharge from 
the nostrils. The mucous membrane is congested and red- 
dened, and the passages soon become occluded by swelling 
and the membranous deposits, which, at times extend contin- 
uously from the posterior nasal orifices to the anterior, oc- 
casioning great embarrassment of respiration. 

In some cases we observe, however, only scattered deposits 
on the mucous surfaces of the septum or turbinated bones. 

The general treatment of this form of diphtheria is in all 
respects the same as in other forms of the disease. The nasal 
passages should be frequently cleansed and disinfected in 
order to prevent putrefaction and secondary blood poisoning 
by absorption of septic matter thus formed. 

In my observation, paralysis of the pharyngeal muscles is r 
doubtless as a result of neglect to cleanse these surfaces,, 
more frequent in nasal, than in other forms of the disease. 
It is, therefore, of the first importance to keep these pas- 
sages as thoroughly cleansed and disinfected as possible. 
This is to be accomplished by the abundant injection of weak 
pure soap-suds two or three times daily, followed by weak 
solutions of chloral hydrate (three to fifteen per-cent), car- 
bolic acid, lactic acid, permanganate of potash, alum, or 
tannin. Preference is given to the chloral solution. 

The nasal as well as the pharyngeal surfaces ma}" be 
effectually treated by inhaling the vapor exhaled by slack- 
ing lumps of lime in a three per-cent solution of chloral 
hydrate, in a wide mouthed bottle. This should be repeated 
every three or four hours. The vapor may be rendered 
aromatic by adding a small amount of any agreeable per- 
fume or essential oil to the liquid used. 



LARYNGEAL DIPHTHERIA. 123 

Should epistaxis occur, and it is not very unusual, it may 
be controlled by injections of Monsell's solution diluted "with 
four to six parts of water, or by the use of a snuff com- 
posed of persulphate of iron one part, and starch three 
parts. 

CHAPTER XIX. 
LARYNGEAL DIPHTHERIA. 

Laryngeal diphtheria, denominated also diphtheritic croup, 
has been fully described in chapter X, to which the reader is 
referred. 

Its differential diagnosis from that other form usually de- 
nominated pseudo-membraneous laryngitis, or true croup, is 
not generally difficult, and yet may at times be nearly or quite 
impossible. To the general practitioner the conflicting argu- 
ments for and against their identity, are of little value or in- 
terest, only as they may possibly influence his treatment of 
the case. Fortunately he is rarety placed under circumstances 
of so equivocal a nature as to occasion serious doubt, and 
should such conditions occur, he can derive little aid from 
controversial writings. The following observations will ma- 
terially aid in properly classifying any given case. 

A case is diphtheria, 1st. "When it is the result of extension 
of diphtheritic inflammation and exudation from the pharynx 
or nares. 

2nd. "When it can be clearly traced to diphtheritic infec- 
tion, and is ushered in or preceded b}^ constitutional pyrexial 
symptoms such as characterize attacks of diphtheria. 

3rd. If the case occurs during the epidemic prevalence of 
diphtheria, and is attended with swelling of the tonsils, the 
parotids, submaxillaries, or the cervical lymphatic glands, any 
or all of them. 

On the other hand, the case is croup, 1st. If it be without 
constitutional symptoms other than those attributable to laryn- 



124 DIPHTHERIA. 

geal inflammation and exudation, as partial aphonia, croupy 
cough, slight fever, and embarrassed respiration. 

2nd. In the absence of diphtheritic exposure, if the disease 
be sthenic in its symptoms, and primarily localty limited to 
the lar}mx. 

The treatment of this class of cases is not shown to have 
been very satisfactory hitherto, as by far the largest part of 
those attacked have died. The 'prevention of larjmgeal com- 
plications, by early and efficient constitutional and local treat- 
ment is, no doubt, much more effective than any means that 
can be emplo3 T ed after the larynx is invaded. But suppose 
la^ngeal s} T mptoms to arise in any case, the earlier they are 
detected, the more hopeful may we be of favorable results. 

It behooves the physician therefore to keep a careful watch 
in every case of diphtheria, in order to detect the approach of 
laryngeal complication, which, as shown in chapter X, is or- 
dinarily heralded by greater or less vocal impairment ; as, 
slight hoarseness of the voice, andcroup}- cough ; or by slightly 
stridulous breathing. All these symptoms are magnified by 
increase of the laryngeal tumefaction and exudation, till by 
occlusion of the larynx the act of efficient respiration is ren- 
dered impossible. 

The general medication in such cases need not be material- 
ly modified except to be pressed with a vigor commensurate 
with the danger. The same is also true of the external local 
treatment, which at most need only be supplemented by effi- 
cient fomentation b} T means of flannels wrung out of hot weak 
solutions of chloral, changed every fifteen minutes. Have 
two sets of flannels, in order that the throat may not be ex- 
posed in changing. Light flaxseed poultices are likewise to 
be commended. 

By far the most important and promising item in the treat- 
ment at this period consists of the administration by inhala* 
tion of fluids vaporized b} 7 " slacking lime, or atomized by aii 
atomizer. For this purpose Mackenzie advises the use of lac- 



LARYNGEAL DIPHTHERIA. 125 

tia acid (gr. xx in J i), to be used at least every hour- and 
continued for five minutes. Prof. Smith gives preference to 
limewater for this purpose, and advises its constant use. 

Having myself had no experience with the lactic acid spray, 
it is sufficient to say that it is strongly advocated by so high 
an authority as Dr. Mackenzie. I have had experience with 
limewater spray, but in my hands it has proven less useful 
than a three per cent, solution of chloral hydrate, and I have 
found its use troublesome on account of incrustations forming 
upon the parts of the atomizer, so as, sometimes at a critical 
period, to prevent its working. 

Believing, therefore, that chloral is a better disinfectant 
and destroyer of the diphtheritic exudate than is limewater, 
as well as more convenient in practice, I advise its use for 
ten or fifteen minutes hourly. The vapor of lime and chloral, 
as advised (see r>17) is specially recommended. 

There must be no relaxation in the administration of nu- 
trients and stimulants, which, if necessary, may be given in 
enemata. 

These measures must be reasonably persisted in till the 
stridor and hoarseness are relieved, and the false membrane 
destrc^ed or expelled. 

If this treatment is not successful, there now arises one of 
the most difficult questions the physician is ever called upon 
to decide ; namely, the propriety of tracheotomy. . Out of the 
greatest perils there is no doubt a few have, by this means 
been rescued ; and from perils apparently equally great, a 
larger proportion have recovered by the persevering use of 
means less violent. I know of no satisfactory statistical or 
other basis for the clear solution of this grave problem. It 
must therefore be largely a matter of individual judgment, 
aided, if possible, by the best available counsel. 

Time, to confer and debate the problem at the bedside, is 
in every case exceedingly brief, from the very nature of the 
case. It may be that even a few moments of apparently 



126 DIPHTHERIA. 

unavoidable delay or doubt will prove fatal ; — instantaneous 
decision and corresponding action are all that remain. 
In the writer's judgment the propriety of the operation in 
any case of general infection is exceedingly doubtful, and un- 
fortunately, such systemic infection exists in ever}' case of 
undoubted diphtheritic pseudo-membranous laryngitis. 



CHAPTER XX. 

TREATMENT OP DIPHTHERITIC PARALYSIS. 

Diphtheritic paralysis, the only frequent sequel of this 

disease, is not ordinarily attended with great danger to life. 

Its mode and period of development, and its attending phe- 
nomena are described in chapter X, which see. 

Although rarely fatal, and tending to spontaneous recovery, 
it by no means follows that medical treatment is unimportant 
in these cases. 

When the paralysis is slight, and limited to the pharynx 
and soft palate, as is most frequently the case, little is needed 
to be done, save careful nursing, with the tonics appropriate 
to this stage of convalescence ; and here, if at all, in diph- 
theria, is an appropriate sphere for iron. Quinine and cod- 
liver oil are also needed. 

In the graver cases of muscular paralysis, there is in 
addition, a need to call to their aid other therapeutical agents, 
If there be marked loss of power of the pharynx and oesoph- 
agus or epiglottis, rendering swallowing difficult or impossible 
in the former, and dangerous in the latter ; the administration 
of nourishment per rectum may become a necessity. For 
this purpose milk with raw egg beaten in it, or strong beef-tea, 
with milk and brandy, are to be used, with the addition of 
a few drops of tincture of opium to prevent immediate 



MEDICAL PROPHYLAXIS. 127 

expulsion. These may also be made the vehicles for the 
administration of remedies, as strychnia, iron, and quinine, 
which are now needed. The feeding and administration of 
medicines may also be effected by means of the stomach tube. 
One or both of these modes may be a necessity to prevent 
death from starvation. 

If the paratysis prove severe or obstinate, we should, 
regardless of its seat, resort, in addition, to electricity, friction 
with the flesh brush or the naked hands, and local stimulants, 
as tincture of capsicum, or ammonia. 

The Writer has been well pleased with the effects of the 
magneto-electric current, though the other electric currents 
in a mild form are recommended. 



CHAPTER XXI. 

MEDICAL PROPHYLAXIS. 

If the views entertained by me of the chloral treatment of 
■diphtheria are well founded, as I believe them to be, and if, 
as I also believe, its effects are produced primarily on the 
blood, and through its medium only, the following sequence 
is, to say the least, logical. 

The effects of chloral being antagonistic to the S3'stemic 
poison, or in other words, antidotal thereto in the more 
advanced stages, it is likely to be equally so during the 
stage of incubation, and therefore an efficient theurapeutical 
proph}iactic. 

That it is such I have often demonstrated in practice, to 
my perfect satisfaction. It manifests a remarkable power 
over the diphtheritic poison in every stage of its develop- 
ment. 

When given to persons exposed, in the doses heretofore 
advised, three or four times in twenty-four hours, I have 



128 DIPHTHERIA. 

almost uniformly observed that if they contracted the disease 
at all, its form was mild. In most instances its protective 
influence has seemed positive, and its use for the purpose, 
though new to most practitioners, is earnestly recommended. 
A little experience in its use will dispel incredulity, and 
prove the value of this new departure. 



CROUP. 



CHAPTER I. 

In its aetiology croup has little in common with diph- 
theria. Croup generally has its origin in colds, and rarely 
occurs except in Winter and Spring, during the prevalence of 
inclement weather, and is neither contagious nor epidemic ; 
whereas diphtheria originates from a subtile blood poison, 
prevails at all seasons of the year, and is both contagious 
and epidemic. Pathologically their relationship consists in 
the development in both of a similar exudation ; in the former 
alwa} T s within the larynx, in the latter almost universally 
upon the pharyngeal surfaces, from which its extension into 
the nares and larynx, as well as its development upon any 
abraded surface of the body, is not rare. We regard both as 
forms of toxaemia, for the reason that common acute inflam- 
mation never, or very rarely, leads to a membranous exuda- 
tion. 

Just what the antecedent or coexistent cause of the blood 
poison of croup may be, aside from the catarrh by which it 
is ordinarily introduced and seemingly induced, is not known ; 
we are only familiar with the course and phenomena of the 
disease. These differ as widely from diphtheria as they do 
from fibrinous bronchitis. All three of these diseases are 
characterized by an identical membranous exudation, but are 
not therefore even suspected of being one disease. There is 
no better reason for suspecting the identity of croup and 
diphtheria than there is for reckoning all three to be one, 
and simplifying the nomenclature by calling all diphtheria. 

9 (129) 



130 CROUP. 

Indeed, Sir J. R Cormack has suggested that plastic bron- 
chitis may be a variety of diphtheria, and numerous other 
writers of great distinction treat croup and tracheal diph- 
theria as identical. Nevertheless the very wide clinical dif- 
ferences observed by all, are sufficient to distinguish them as 
separate diseases, having the one characteristic, a lamellated 
membranous exudation, in common. 

Their histories are as distinct as their clinical differences, 
and both alike disprove their identity. . . . The common 
membrane, it must be admitted, is suggestive of a similar 
effect being produced upon the blood by the causes which 
call into existence these separate affections. Although com- 
mon forms of inflammation never produce such an exudation, 
it does not follow that the different causes of these diverse 
maladies may not, to some extent, similarly affect the blood, 
and be amenable to like treatment. 

Fibrinous exudations prove either such an affection of the 
blood as predisposes to coagulation, or a peculiar form of 
local inflammation, producing topically, in croup and plastic 
bronchitis, a condition that in diphtheria has been shown to 
be systemic. Either may be admitted, or both, without ma- 
terially influencing the treatment, for the reason that, in the 
presence of so great danger, no topical or general treatment, 
known to have a favorable influence is likely to be disre- 
garded, whether it exactly fits our philosophy or not. 

The disease now under consideration is given a variety of 
appellations, as pseudo-membranous laryngitis, croupous or 
plastic laryngitis, cynanche trachealis, membranous croup, 
true croup, etc., to distinguish it from other varieties of 
laryngeal inflammation. The term croup, which was first em- 
ployed by Sir Francis Home, has long been applied to this 
malad} T , and is expressive of its earliest symptoms, hoarse- 
ness and stridor. Its derivation is uncertain and unimpor- 
tant, while its true meaning is expressive and significant. 
" Croupy 'cough" and " croupy breathing" are popular ex- 



CROUP. 131 

pressions that are never misunderstood nor disregarded by 
medical men, and very seldom by the laity. They inspire the 
popular and the professional mind alike with a well-grounded 
sense of impending suffering and imminent peril. 

The disease is essentially a plastic laryngitis, dependent 
largely for its origin upon exposure in inclement weather, 
and in some degree perhaps upon specific causes, and also 
upon peculiar personal or family susceptibility ; and not upon 
any peculiar contagium. 

Croup is essentially a disease of childhood, between the 
ages of two and seven years, but occasionally occurs outside 
of these limits. It prevails mostly during Winter and Spring 
and is only exceptionally observed during Summer and Au- 
tumn. Its occurrence as a consequence of or in immediate 
connection with common acute catarrh, so masks its stealthy 
invasion that its serious character is often unsuspected : the 
patient is thought only to have " caught a cold." 

Early symptoms and diagnosis. First Stage. Pseudo-mem- 
branous laryngitis in its early stages is with difficulty diag- 
nosed from simple or ordinary catarrhal inflammation. Its 
symptoms are such as depend solely upon laryngeal obstruc- 
tion. This obstruction is at first, as in all the other forms of 
laryngitis, due to sub-mucous infiltration, or inflammatory 
swelling. An inflammatory stage, as in diphtheria, precedes 
the exudation or the period of membranous formation. Then 
as croup is, unlike diphtheria, neither epidemic nor conta- 
gious, no reliable diagnosis can be based upon its epidemic 
prevalence, or upon exposure depending upon the presence 
of others affected by the disease. The slight roughness or 
hoarseness of the voice and clanging or barking cough, as 
before intimated, are no more, often less, marked in the croup- 
ous than in simple catarrhal or accute forms of laryngeal in- 
flammation. Auscultation shows that both the inspiratory 
and expiratory sounds are a little prolonged, and that the 
vesicular murmur is more or less marked by laryngeal stri- 



132 croup. 

dor. The supraclavicular, intercostal, and precordial spaces 
are somewhat depressed during inspiration, the depression 
being in proportion to the obstruction. Neither rigor, pro- 
dromic symptoms, nor peculiar form of fever, indicates the 
true nature of the attack, any more than do the character of 
the voice and cough. No characteristic expectoration or fau- 
cial inflammation Or adenitis are so manifest as to enable the 
anxious practitioner to surely solve the problem of diag- 
nosis. Is its solution then impossible ? It is only just to 
confess that, in the early stages, it sometimes is impossible. 
With physicians of experience and culture, and quick percep- 
tion of cases, a diagnosis is often like an intuition or a super- 
added sense, and is no more communicable to a novice by 
words than are the most difficult problems of geometry. 
This superadded sense or ready interpretation of the physi- 
ognomy of disease is a large element of medical proficiency, 
and either is, or underlies, skill. What, then, we inquire, are 
the best communicable instructions to aid junior members of 
the profession to fix upon a diagnosis in the early stages or 
first period of croup, as a basis for the treatment of this 
most deadly foe of children ? 

1st. Remember that the characteristic symptoms are gen- 
erally (not always, it must be confessed,) more slowly devel- 
oped than in the simple inflammatory or spasmodic forms of 
larj-ngeal obstruction. The cough and stridor are less marked 
and more insidious and prolonged in this early period, than 
in the usually harmless spasm of the glottis, whether 
accompanied or not by some degree of inflammation. 

2d. Fever is induced alike in the simple and the croupous 
forms of laryngitis, and hence is not pathognomonic. It may 
be said often to appear earlier, and at first with greater vio- 
lence, in the simple form of laryngitis than the croup. 

3d. The differential diagnosis, to be reliable, must depend 
upon the discovery of the pseudo-membrane. If we are able 
to make visible the interior of the larynx by means of the 



CROUP. 1% 

laryngoscope, the presence or absence of this formation will 
remove all doubt. This method is not alwa3 r s practicable, 
and with timid children, sufferino; often as much from friffht 
as from dyspnoea, is very generally impossible. " If," sa}~s 
Prof. Flint, " the demonstration by this method fails, the pros • 
ence of a false membrane is to be inferred, first, from the de- 
gree of obstruction being greater than in simple acute laryn- 
gitis, provided the patient be a child; and second, from the pres- 
ence of an exudation in the pharynx, which is determinable by 
inspection of the throat. The latter is by far the more reliable. 
Clinical observations go to show that, in the great majorit}- 
of cases, an exudation visible in the pharynx accompanies 
pseudo-membranous laryngitis exclusive of the occurrence of 
the latter as a complication of diphtheria. There are, how- 
ever, some cases in which this evidence is wanting. In these 
cases a positive diagnosis cannot be made independently of the 
laryngoscope, until portions of the false membrane have been 
expelled by coughing. In all cases the expectoration should 
be carefully examined with reference to this, point. The por- 
tions of false membrane expectorated are sometimes rolled 
together with the mucus into a mass which must be carefully 
unrolled in water, in order to determine its membranous char- 
acter. This evidence of the affection is rarely obtained if the 
patient be under five jeavs of age on account of the expec- 
toration beino- swallowed." 

These remarks by this great teacher serve more to show 
the difficult character of the problem under consideration 
than to aid in its solution ; although it must be acknowledged 
thej' are as truthful as they are characteristically frank and 
instructive. 

Let us call to our aid a clinical example. E. S., aged five 
years, contracted a cold from exposure Nov. 12th, 1880. 
Family are constitutionally predisposed to croup, two children 
having previously died of the disease. Parents and living 
children constitutionally sound except the predisposition 



134 croup. 

above mentioned, which has also been manifested by several 
violent attacks of diphtheria. Sanitary surroundings and 
other circumstances reasonably good. When called on the 
15th the patient appeared but slightly ill; for three days had 
had a cold and been moderately but increasingly hoarse, with 
croupy cough keeping pace with the hoarseness, appetite im- 
paired, fever so slight that of itself it would not attract at- 
tention ; had a rather restless night, respiration slightly stridu- 
lus and distinctly audible. No view of the interior of the 
larynx could be obtained ; epiglottis and adjacent parts con- 
gested and coated parti}' with what appeared to be condensed 
mucus, no djsphagia nor glandular swelling. Diagnosis 
membranous laiyngitis. 

If in this stage any doubt may have existed, the subsequent 
history showed unequivocally the correctness of the diagnosis. 

At this early period of the disease, the symptoms as epito- 
mized by Bartholow, are as follows. The attack of the croup 
usually but not invariably begins as an acute catarrh of. the 
lar}-nx ; there is a feeling of heat and irritation in the organ, 
and the voice is a little husk} T ; there is cough with something 
of stridor about it ; and fever, restlessness, thirst, anorexia, 
and disturbed sleep accompan3 r the evidences of laryngeal 
mischief. When the fauces are inspected, more or less red- 
ness, sometimes dusky redness, will be observed, and also 
small patches of a thin pellicular exudation of a grayish-yel- 
low color, studded over the palate, tonsils and pharynx. 
These patches presently coalesce and then form a dense mem- 
brane several lines in thickness (?), of a yellowish gray or 
ash color. As huskiness of voice was one of the initial symp- 
toms, the same patches of pellicular exudation are forming in 
the larynx. 

Evening exacerbations, followed, as morning approaches, by 
remissions, are, during this period, extremely common, but are 
at most only suggestive, and not to be considered diagnostic. 
Says Prof. Mackenzie : " In children it is sometimes very 



croup. 135 

difficult to distinguish catarrhal laryngitis of a severe form 
from croup. Indeed, in the early stages it is often impossible 
to differentiate the two maladies." 

On the other hand J. Lewis Smith (Diseases of Children) 
writes : " The diagnosis of true croup is ordinarily easy. It 
might be mistaken for spasmodic laryngitis, but more frequent- 
ly spasmodic laryngitis is mistaken for it. The differences 
which will aid in the differential diagnosis are the following : 
Commencement abrupt and at night in the one, gradual in the 
other ; presence in one and absence in the other of pseudo- 
membrane upon the surface of the fauces ; fragments of mem- 
brane in the sputum in one ; character of the cough, course of 
the disease growing gradually in one, in the other, with few 
exceptions, rapidly improving." Trousseau speaks of the lia- 
bility to eiTor of diagnosis in these cases in which spasmodic 
laryngitis is associated with pseudo-membranous pharyngitis. 
" Few phj^sicians hesitate to designate as true croup these cases 
in which there is a croupal cough in connection with false mem- 
brane upon the surface of the fauces, and yet the laryngitis, 
under such circumstances, may be merely spasmodic. This 
coexistence of pseudo-membranous pharyngeal and of spasmo- 
dic laryngeal inflammation is, however, probably rare, but its 
occasional occurrence should be borne in mind." 

Just how Prof. Smith has rendered the " diagnosis of true 
croup easy " in the preceding quotation is not easy to see, as 
he has failed entirely to notice the difficulty of differentiating 
the disease from catarrhal laryngitis, which Mackenzie truth- 
fully declares " is often impossible." Much of the apparent 
clearing up of the diagnosis of true croup comes from its be- 
ing considered by Trousseau, Mackenzie, Bartholow, and others 
as identical with diphtheria ; hence the frequent reference to 
the discovery of membranous deposits on the pharynx as 
diagnostic of croup : it is, however, more commonly pathogno- 
monic of diphtheritic infection, and its appearance is excep- 
tional and rare in uncomplicated true croup. A certain diag- 



136 croup. 

nosis at an early period of the disease is frequently simply 
impossible. 

Later Symptoms. As the disease advances the skin becomes 
hot and drj T , the face flushed, e3 T es suffused, breathing more 
hurried and stridulous, cough more hoarse and frequent until 
it becomes toneless, a mere spasmodic expiration ; the labored 
and hoarse phonation is nearly, and finally entirety extin- 
guished. The patient, already suffering from asphyxia, be- 
comes alternately dull, and fretful and passionate. Then 
occurs a lull, respiration somehow is a little easier, probably 
in consequence of relaxtion of the lanmgeal structures, the 
effect of the increasing carbonic acid toxaemia, and the patient 
not only breathes better, but from better ox} T genation of the 
blood becomes temporality less stupid, and for a yery brief 
period seems quite himself again. Yery soon, however, as the 
irritability of the laiyngeal structures is revived, spasmodic 
stricture is again added to the organic obstructions, the dys- 
pnoea returns with increasing violence; the lips and nails be- 
come blue, every respiratory muscle seems to exert its utmost 
power to obtain the required air, inspiration is prolonged and 
stridulous, the intercostal spaces are depressed; the veins of 
the face and neck become prominent, and a profuse perspira- 
tion bursts from eve^ pore. Expiration, though obstructed 
and often prolonged in proportion to the amount of air exhaled, 
is less painful, because not accomplished in so great a measure 
by the direct labor of the exhausted respiratory muscles. 

The effects of the intense labor, and the accumulated car- 
bon in the blood, soon again produce exhaustion and insensi- 
bility, and the patient again falls asleep. A brief period of 
restless repose and labored breathing is soon succeeded by 
another paroxysm even more violent than the preceding. The 
cough does not increase in violence as the disease progresses 
on account of the muscular debility, and is rarely of sufficient 
force to raise the mucus from the air passages, or to detach 
and expel the loosening portions of false membrane. The 



croup. 137 

paroxysms of coughing not only do not afford relief, but on 
the contrary, by lifting the thick mucus or detached portions 
of membrane to the rim of the glottis, add to the existing 
obstruction, occasioning increased spasm, and may thus pre- 
cipitate a fatal termination of the case. The voice during 
this period is usually extinguished, or so great is the effort 
necessary to speak, or so painful, that onby a feeble whisper 
or sign can be elicited. 

The appetite for food is entirely lost, the thirst incessant, 
and deglutition not generally difficult. The tongue is heavily 
coated with a thick white fur except the tip and edges, which 
are often intensely red. The fauces are red, or ash colored, and 
occasionally show traces of membranous exudation, but af- 
ford no index to the violence of the disease. 

During the third staje, which now supervenes, the exacerba- 
tions grow less violent as the natural forces decline, and the 
intermissions fail to recur, while the respiratory effort is con- 
stantby taxing to the utmost the waning vital and muscular 
force. The cough grows more feeble or ceases entirely ; the 
breathing apparently less laborious is feeble and sibilant. 

The head is forced backward as in opisthotonos, the larynx 
depressed and alternately moving up and down in aid of the 
respiratory efforts, which with the co-operation of the abdomi- 
nal muscles causes the chest to heave violently to increase its 
capacity, and force the entrance of air. The countenance 
grows livid and anxious, the eyes dull and pale, the skin dry 
or clammy and the extremities cold. The pulse becomes very 
feeble and rapid, the respirations irregular or intermittent : the 
patient throws himself about upon the couch, often clutching 
the throat in frantic fruitless efforts to remove the obstacle to 
breathing. The agony increases, the countenance gradually 
relaxes, and eitb^r increasing dyspnoea, coma, or convulsions, 
hasten the tragic scene to a close in death. 

Death may occur at almost any period of the disease. 
Fatal cases rarely run a longer period than two weeks, or a 



138 croup. 

shorter than two days. In the earlier periods sudden death 
is often, no doubt, the result of spasmodic closure of the 
glottis. Later it may result from the great extent and thick- 
ness of the membrane, or from detached portions lodging in 
the chink of the glottis. Still another cause of death may 
be found in the bronchial obstruction, caused by mucus and 
pus, which the feeble patient has been unable to expectorate ; 
and yet another cause of death may be the imperfect aeration 
of the blood from imperfect respiration, and the consequent 
gradual accumulation therein of carbonic acid. 

Pathology. The post-mortem appearances are in accord 
with the disease phenomena heretofore delineated. As death 
rarely occurs during the first period, few opportunities are af- 
forded of determining the anatomical characters which then 
exist, but as the hoarseness and croupy cough are primarily 
due to inflammatory congestion and tumefaction, during the 
first period, only the evidences of such action are known to 
exist. These consist of intense injection of the larynx, 
either uniform or in patches, swelling, and a scanty secretion 
of tenacious mucus, or elementary pseudo-membrane. In its 
later stages, after the lrypersemia has attained its maximum 
intensity, the disease is characterized b}^ the appearance upon 
the inflamed surface of a grayish-white semi-transparent pel- 
licle or rudimentary false membrane, which rapidly increases 
in thickness, and which presents much the same physical and 
chemical properties as the pseudo-membrane formed in well 
marked cases of diphtheria. It is not of uniform density, 
and is found more firmly adherent at some points than at. 
others ; often it is found loose, or being only partially de- 
tached hangs in shreds or fringes. Its thickness varies from 
a mere pellicle to several lines. Its location is chiefly in the 
interior of the larynx, coating the vocal cords, the ventricles, 
and lower surface of the epiglottis. It is occasionally visible 
upon the pharyngeal surfaces, but probably less frequently 
than is often estimated. 



croup. 139' 

The formation of the pseudo-membrane in the trachea is 
also common, and may extend downward to the minutest 
bronchi, so completely obstructing the passage of air as to 
have induced emphysema or atelectasis. According to Guer- 
sent, in 120 cases, the false membrane was limited to the- 
larynx and trachea in 78, and in 42 extended also into the 
bronchial tubes. It is seldom so abundant in the larynx as 
to completely close it against the entrance of air, but on the 
contrary, necropsy often reveals there merely a transparent 
pellicle. The dyspnoea which during the first period was due 
solely to inflammatory tumefaction, was subsequently, in such 
cases, probably due to spasm of the glottis, excited by the 
presence of the pseudo-membrane, just as any foreign particle 
causes such spasm in health ; for it should be borne continu- 
ally in mind that the most violent paroxysms of dyspnoea, 
are in nearly all cases, largely due to spasm. 

The pseudo-membrane, then, surrounded generally with epi- 
thelial debris and mucus and pus, is the peculiar characteris- 
tic of croup, as seen by the anatomist, and in the absence of 
this, no pathologist could venture to pronounce a case pseudo- 
membranous laryngitis. 

Treatment. When we consider the great danger from the 
rapidly increasing obstruction to respiration in this disease, by 
the increasing congestion of the larynx and the deposit of 
plastic matter upon its walls, in connection with the natural 
narrowness and sensitiveness of the chink of the glottis in 
young children, in whom slight turgessence of its mucous 
membrane is often sufficient to cause stridulous breathing 
and alarming spasmodic closure, the importance of early 
treatment can hardly be exaggerated. 

Indications. The arrest of inflammatory congestion, limit- 
ing or preventing the adventitious deposit, or if already 
formed effecting its disintegration or expulsion and the 
prevention of spasm are the chief therapeutical indications. 
While pursuing these objects, the necessity for properly 



140 CROUP. 

supporting the patient's strength so that he may be able 
to withstand the progress of the disease, must of course 
be borne in mind, and is to be effected by suitable nutrition, 
and avoidance of such measures of treatment as tend to 
induce undue depression. 

Of remedial measures having the sanction of most authors 
we first notice emetics. Their effects are, 1st: To diminish 
the local congestion by occasioning copious secretion and ex- 
pulsion of mucus. 2nd: To detach the pseudo-membrane 
by increasing the secretion beneath it, and softening it, 
and by the expulsive efforts occasioned, to effect if possi- 
ble its dislodgment and ejection with the matter vom- 
ited. Emetics are, therefore, generally considered the proper 
initial of rational treatment. As it is manifestly important 
to consider the strength of the patient, that he may be able 
to bear up against the ravages of the disease, and be able in 
the succeeding periods thereof, by vigorous cough and 
repeated administrations of the remedy if needful, to effect 
the object in view ; it is essential to select such emetics as 
occasion the last prostration. Their repetition, to vigorous 
patients, as often as three to five times in twenty-four hours, 
it is thought, is often beneficial. Antimonials, which were 
formerty much in vogue, are therefore manifestly improper, 
and must be rejected. Ipecacuanha in substance, or in the 
form of sirup or wine, although less depressing, is yet ob- 
jectionable unless with robust subjects, because of the con- 
tinued nausea and resulting debility. Sulphate of aluminum 
in doses of a teaspoonful suspended in sirup or honey, given 
every ten or fifteen minutes till free emesis is produced, is 
highly commended b}' Prof. Meigs of Philadelphia and others, 
and is one of the best of this class of remedies ; the large- 
ness of the dose is the only objection to its use. Sulphate 
of copper is another of the most prompt and least objection- 
able of emetics in croup. It is conveniently administered 
powdered with an equal weight of ipecac, and suspended in 



CROUP. 141 

sirup so that each drachm may contain four or five grains of 
the mixture, and is given in teaspoonful doses every five- 
minutes till it operates. It has been administered as often 
as every two to four hours with apparently good results. So 
frequent administration is not generally to be advised. The 
yellow sulphate of mercury in two or three grain doses, to 
a child of two 3 T ears, is highly praised by Dr. Hubbard, Prof. 
Fordyce Barker, Prof. J. L. Smith, and others. Dr. Barker 
gives the remedy without delay, and claims not to have lost a 
patient thus treated for several years. The dose should be 
repeated in ten or fifteen minutes if the first dose does not 
produce emesis. Its employment is sanctioned by the very 
best authors, and is commended by the writer, although par- 
tial to sulphate of copper. 

If there be any degree of constipation, mild cathartics 
should be early administered. 

After emesis, resort must be had to those remedies known 
to prevent or diminish plastic exudations, acting through the 
blood ; also to the topical use of such as tend to remove 
such exudate by effecting its separation or solution. The 
chief remedies of this class are mercury, chlorate of potassa, 
chloride of ammonium, quinia, bromide of ammonium and 
chloral hydrate. 

Mercury. This remedy, which is usually administered iir 
the form of calomel, has been highly recommended b}^ nearly 
all reputable authors of the past century. " Dr. Samuel 
Bard states that Dr. Douglas of Boston, who published in 
the year 1736 an account of the angina suffocativa, was the 
first to recommend the employment of mercuiy in croup. 
Bard says that he was induced to tr} r mercurials after read- 
ing Dr. Douglas's little essay, and adds, 'The more freely I 
have used them, the better effects I have seen from them/ 
To patients three or four } T ears old he gave thirty or forty 
grains in five or six days, 'not only without any ill effects, 
but to the manifest advantage of my patient j relieving the 



142 croup. 

difficulty of breathing, and promoting the casting off of the 
slough beyond any other medicine.' He advises the first 
dose or two combined with opium, and considers mercury 
the basis of cure in croup." (Meigs.*) 

We certainly know that calomel has the effect of increasing 
and attenuating the expectoration, but whether it also in- 
creases the secretion within the larynx and beneath the 
pseudo-membrane and thus assists in its detachment, is not 
so easily demonstrated nor generally conceded. But this 
remed} 7 has also an ancient and honorable reputation as an 
anti-phlogistic and alterative. On account of the former 
propeily it has been, and still is to a considerable extent, 
reputed to be the great antagonist to inflammation ; hence 
it has generally been advised to continue its administration 
till the inflammation subsides, or the mouth becomes con- 
siderably affected. 

As an alterative its effects are produced through the medium 
of the circulation. By its effects upon the blood or the dis- 
ease elements, it is well known in some maladies, as syphilis, 
to have the power so to modify it as to effect a cure. 

This power of producing an alterative effect upon the blood 
has been invoked in the treatment of croup. Its reputed 
efficacy in so modifying the blood as to diminish or prevent 
membranous exudation, has been sustained by the ablest 
writers. Prof. West, of St. Bartholomew's Hospital, London, 
wrote, "Calomel seems to have a twofold utility; it counteracts 
the tendency to the formation of false membrane in the air 
passages, and prevents or subdues that inflammation of the 
lungs which is so frequent and so fatal a complication of this 
disease." Says Coley, of London, " One or two grains of 
chloride of mercury must be given immediately, and repeated 
every hour, until the inflammation has subsided, or the mouth 
has become sensibly affected." Prof. Meigs says, "It (calomel) 
ought to be given early in order to produce upon the blood its 
defibrinizing effect, and thus prevent, or at least limit, the ex- 



croup. 143 

tension of the deposit." Such evidence of the utility of mer- 
cury in croup, from eminent authors, might be made to em- 
brace almost the entire list of medical writers up to a very 
recent date. If to the mass of writers, we add the oral testi- 
mony of a great multitude of living eminent practitioners, a 
strong case is certainly made in favor of the use of mercury 
in this disease, and it is not too much to concede the proprie- 
ty of its employment. 

The approved mode of administering this potent remedy 
may be thus epitomized. To a child one or two years of age 
give from gr. ss to gr. i, either alone or combined with enough 
pulv.Dov. to prevent its cathartic effect. At the age of five 
or six years the usual dose is gr. i to gr. ij. These doses are 
usually repeated at intervals of two hours, and in violent 
cases are given hourly. Prof. Meigs affirms that of nine cases 
so treated by himself, six recovered ; while of seven cases 
treated without mercury, five died ; showing a balance in favor 
of mercurial treatment of 50 per cent, in the proportion of re- 
coveries. It should be borne in mind that with mercury the 
other approved adjuncts, as emetics, moist air, &c, were con- 
joined. 

Notwithstanding the affirmed utility and high repute so 
long enjoyed, of mercurial medication in croup, the title to its 
venerable reputation is at the present time greatly questioned. 
Prof. Mackenzie omits even its mention among the reputable 
remedies, whilst by some other recent writers it is noticed only 
to distrust, or to condemn. Neither the theory upon which 
the practice is based nor the practice itself is any longer re- 
garded as invulnerable. It must be confessed that the finest 
theories of medical scientists are at the mercy of clinical facts. 
Let it be proven as stated loy Meigs and others that fifty per 
cent, more cures are obtained by this treatment than by any 
other, and we shall soon see that an improved version of science 
will furnish an improved theory. If on the contrary, careful 
observation shall prove the superiority of more recent modes 



144 croup. 

and remedies, no reverence for antiquity, nor list of worship- 
ing admirers, can save this venerable giant from humiliation. 

Chlorate of potash is very generally prescribed in some way 
in pseudo-membranous laryngitis, although both its modus 
operandi and the benefits resulting from its use, are questions 
still far from being satisfactorily settled. It was first pro- 
posed as a remedy in croup by Chaussier in 1819, but soon 
fell into complete disuse. It was revived again by Blache, 
and has ever since been used, in connection with other reme- 
dies, with more or less belief in its beneficial effects. It is re- 
garded by Trousseau as "having a general influence over the 
system opposing the reproduction of plastic exudations," and 
he adds, "Nothing forbids the use of this remedy in so dread- 
ful a disease as croup, without, however, placing exagge- 
rated confidence in its virtues, and especially without using 
it to the exclusion of other treatment of proved (though per- 
haps limited) efficac}'." 

Its excessive use is thought to induce inflammation of the 
kidnej'S with albuminaria. Its possible dangers, therefore, 
and equivocal benefits in croup, should guard against its too 
liberal administration. 

Ammonium Chloride^ administered internally, has long en- 
joyed the reputation of having a specific tendency to the mu- 
cous membrane of the air passages, improving its tone and 
favorably modifying its secretion. "The idea which has ap- 
peared chiefly to direct its use in medicine is, -that it tends to 
render all the secretions freer and more abundant, while it at 
the same time lessens the plasticity of the blood, in other 
words, that its operation is, in some respects, identical with 
that of mercur}'," for which it has been b}^ many physicians 
extensively substituted in practice. Notwithstanding the sug- 
gestiveness of its reputed physiological action, it has but 
recently assumed an important rank in the therapeutics of 
croup,, and in this disease is now used to a considerable ex- 
tent both in private and hospital practice. Prof. J. Lewis 



CROUP. 14& 

Smith writes of its use in Bellevue Hospital, as follows 
(Diseases of Children, p. 511) : " Calomel has been much used 
in times gone by for its supposed antiplastic action, and more 
recently muriate of ammonia and chlorate of potassa as in the- 
following formula. 

3 Potas. chlorat. 3 i. 
Ammon. muriat. 3ss. 
Syr. simplic. 3 ss. 

Aquse 3 ij. Misce. 

Give one teaspoonful every half hour or hourly. 

" Since the discontinuance of the calomel treatment, this 
mixture has been largely used in New York, but is now being 
superseded by the atomizer, or it is being employed along with 
the atomizer." 

Quinia and bromide of ammonium are accounted most valu- 
able remedies in croup, especially by Bartholow. Quinia in 
full doses of gr. iii to gr. v with children, inducing and main- 
taining cinchonism as fully as possible, is thought to effect 
the arrest of plastic exudation. Bromides, by their elimina- 
tion by the bronchial and faucial surfaces, no doubt exert a 
beneficent local effect in addition to their efficacy as anti- 
spasmodics in controlling the larjmgeal spasms. The bromide 
of ammonium is given the preference, and is recommended in 
full doses in alternation with quinia. 

Chloral hydrate is believed by the author to have proven 
itself more efficacious in the treatment of croup than any other 
individual remedy. For seven years it has been freely used 
in every case treated by him, with much better results than 
had hitherto been obtained without its use. In eight cases 
since 1876, of such gravhry as is usually thought to demand 
tracheotomy, six, by its persistent use, terminated in recovery \ 
and in no single instance since its introduction has resort to 
this formidable operation been thought advisable. 

The spasmodic affection of the larynx, which constitutes so 
dangerous a complication in this disease, is so perfectly con- 
10 



146 croup. 

trolled bj r chloral as to be almost eliminated from its danger- 
ous symptoms. This effect might reasonably be expected 
from its well established efficacy in other spasmodic affections. 

It will be observed that chlorine is an element in all the 
reputed anaplastic remedies employed in croup, and from the 
immense amount of this element emplo3 T ed in the manufact- 
ure of chloral, it might on this ground reasonably be sup- 
posed to be superior to them all. Having already, when pre- 
senting its claims to specific action in diphtheria, shown its 
effects upon the blood to preserve its fluidity and to prevent 
or arrest the tendency to fibrinous coagulation or exudation, it 
is sufficient in the present case to refer the reader to that part 
of this volume, with the remark that its therapeutic efficacy 
in croup is believed to be as rational and as well established 
as in that disease. 

It is believed its use in the treatment of croup originated 
with the writer about the time of its introduction by him in 
the treatment of diphtheria, and so far as known, Prof. Bar- 
tholow alone among standard authors, has arrived at similar 
views, or commended its use in this disease. He says (Prac- 
tice of Medicine, p. 437), " Besides the agents above advised, 
quinia and the bromides — for the laryngeal spasms chloral is 
to be commended. The author has preferred to give chloral 
:and bromide of ammonium together, and the quinia separate- 
ly. Besides its power to allay spasms, chloral is one of the 
few remedies which possess the property to check the forma- 
tion of an exudation." 

To assure its greatest efficiency, it should not only be given 
earry in the disease, but should be given freely and persist- 
ently. To a patient two or three years old either of the 
formulae, 23 or 24, may be employed in appropriate doses every 
hour or offcener when awake. For older patients the dose 
should be proportionately large, and in any case increased or 
diminished according to circumstances, special reference being 
had to the soporific effects of the chloral. If the tendency to 



croup. 147 

sleep is strong, a less dose is indicated. Its employment does 
not in any way interfere with the administration of emetics 
when indicated, nor with any other measures deemed necessary. 

Moist air being more easily respired in this disease than 
dry, it is advised that the atmosphere inhaled by the patient 
be impregnated with steam, either alone or medicated. Chlo- 
ral and lime in the form of vapor or spra} T is. regarded the 
most important. An eligible and economical mode of sup- 
plying the vapor consists in slaking lumps of fresh lime in 
an open-mouthed bottle, or in a coffee-pot closely covered and 
rendered tight by placing wet cambric beneath the lid, and so 
held as to compel the patient to inhale the vapor as it arises 
or is discharged from the spout, or rubber tube attached. 
A coffee-pot, or any similar vessel, with the spout placed 
near the top, is to be preferred, as it furnishes a more 
dense vapor, which can be easily directed to the nostrils of 
the patient. The water used for slaking the lime should 
contain from ten to twenty grains of chloral hydrate dis- 
solved in each pint. The vapor may be made aromatic by 
adding to the water a small quantity of some agreeable 
perfume. The inhalations should be commenced as soon 
as the disease is recognized, and continued as long as the 
hoarseness persists. Each inhalation should continue ten to 
fifteen minutes, and should be repeated every hour or oftener 
in the early stages, and less frequently as the disease subsides. 

No case of croup can be efficiently treated so as to afford 
the patient the best chance of recovery, without resort being 
had to inhalations of either the above or similar vapors, or of 
atomized fluids possessing like qualities. The old method of 
slaking lime in open vessels, thus filling the sick-room with 
the vapor, is both awkward and wasteful, as well as disagree- 
able and dangerous to the attendants, rendering them exceed- 
ingly liable to take cold upon going into the open air. 

Spray inhalations, though believed to be less efficacious, 
may be used instead of the above. Those of lime-water and 



148 croup. 

chloral, separate or combined, the author considers most 
efficacious. (Nos. 10, 11, et seq.) 

For use in this way Mackenzie recommends lactic acid (16). 

J. Lewis Smith recommends the nearly constant use of 
lime-water four parts, and glycerine one part, only intermit- 
ting its use every second hour long enough to inhale one 
ounce of No. 14. 

When portions of false membranes are thought to be loose, 
or the passages are greatly obstructed by mucus, prompt emet- 
ics are indicated, and if not successful in dislodging and 
expelling the obstructing matter, recourse may be had to the 
use of a small soft probang or brush for the purpose. 

The local application of cold water and of ice have been 
advised, but are uncomfortable to the patient, and hence re» 
sisted by him, and opposed by the attendant friends as "being 
a harsh and hurtful expedient. 

Emollients rendered antiseptic, as glycerine with chloral 
h} T drate (grs. v to x in 3 i), or camphorated oil, or light 
warm linseed poultices, are preferred by the writer, and 
are recommended. 

The patient should be well nourished, and allowed agreeable 
beverages. Milk and beef juice or essence, with soft farina- 
ceous preparations, as panada, arrowroot, cornstarch, &c, with 
custards and syrups, may be given according to the judgment 
of the practitioner and the taste of the patient. 

Finally, the grave question of tracheotomy may be forced 
upon the attendant physician from the apparent failure of the 
timely and persistent use of the best remedies at his com- 
mand ; for it is certain that this grave issue must occasionally 
be faced, despite the important addition of chloral to the 
therapeutics of this dangerous disease. The indications that 
call for the performance of this operation are solely such as 
relate to the respiration. In brief, it is necessary and justifi- 
able after all other remedies have failed, and impending 
suffocation can only be averted by making an artificial aper- 



croup. 149 

ture into the windpipe in order to render respiration possible. 
This procedure, surely to be followed hy the death of a 
large majority of its subjects, can never be justified upon the 
plea of conservation, in order to forestall and anticipate dan- 
gers which either may or may not occur, but only, as it were, 
in the presence of death itself, with all it implies. Since using 
the chloral treatment I have witnessed a larger proportion 
of recoveries from conditions usually thought to demand the 
operation, bat in which it was not performed, than is shown 
by the most favorable statistics to have resulted from its per- 
formance. Six out of eight such cases I have seen recover 
from the use of therapeutical measures alone, while the best 
results obtained in the best institutions, D3 7 the most experi- 
enced and skillful surgeons, in this country and Europe, 
scarcely average a single recovery in less than five cases 
operated upon. Between the years 1849 and 1858, according 
to Trousseau, 466 cases operated on in the Children's Hospital 
in Paris, 126 recovered, and 340 died. In 1863, so far as 
ascertained by careful research, the proportion of recoveries 
at the Hospital des Enfants Malades, was one in four ; at the 
Hospital Sainte Eugenie, one in six. In the latter, from 1854 
to 1875 inclusive, one in four and fifty-four hundredths, and 
in the former, from 1851 to 1875 inclusive, one in three and 
eighty-two hundredths. The statistics of Paris probably repre- 
sent the best results attainable by this operation in croup by 
the most skillful and experienced operators. 

In England and America the results are not known to be 
more encouraging ; practically they are identical and hence 
need not be repeated. 

We repeat then, only the gravest conditions can justify so 
equivocal a procedure. The conditions demanding and justify- 
ing such an operation are those relating to the degree of laryn- 
geal obstruction. It is manifest that occlusion of the trachea 
below the point of operation, or of the bronchi, not only 
could not be remedied by tracheotomy, but contraindicate its 



150 CROUP. 

performance. The degree of laryngeal obstruction is indi- 
cated by the greater or less respiratory stridor, and is still 
further evinced by being accompanied by evidences of insuf- 
ficient aeration of the blood, as blueness or lividity of the lips 
and finger tips. When such evidences of asphyxia exist and 
can in no other way be relieved, then it is clearly time to have 
recourse to tracheotomy. To delay in the presence of these 
portentous symptoms is even more dangerous than the opera- 
tion. Therefore it is now clearly a duty to open a passage for 
respiration, or it must cease. 

It is advisable that this extremity, which may occur sud- 
denly and unexpectedly, should be anticipated by careful pre- 
paration for prompt action. Have in readiness one or more 
double canulae, in addition to the instruments for making the 
incision, which are usually found in every surgeon's pocket 
case. Every plrysician liable to be called upon to perform the 
operation is supposed to have familiarized himself with its 
details, its dangers, and subsequent management, by a knowl- 
edge of the teachings of the best surgical authors. 

For succinct advice and directions regarding this proced- 
ure (tracheotomy), attention is likewise called to chapter 
XXIII, which has been kindly furnished for this volume by an 
able, skillful, and experienced operator, R. A. Vance, A. M., 
M. D., late Professor of Operative Surgery and Clinical 
Surgery in the Medical Department of the University of 
Wooster. 



TRACHEOTOMY. 151 

CHAPTER XXIII. 
TRACHEOTOMY. 

' BY R. A. VANCE, A. M., M. D. 

Systematic writers describe three operations for the relief of 
obstructive disease of the air-passages — laryngotomy, laryn- 
go-tracheotorny and tracheotomy. In laryngotomy the open- 
ing is made through the crico-tlryroid membrane. Laryngo- 
tracheotomy involves an incision into the crico-thyroid, 
membrane primarily, followed by section of the cricoid 
cartilage and adjacent rings of the trachea. In tracheotomy 
the surgeon opens the trachea by a vertical incision in the 
middle line of the neck. There is no department of surgery 
in which more erroneous notions prevail than in that which 
pertains to operations upon the windpipe. These errors- 
relate not only to the supposed facility with which the air- 
passages can be opened, but extend even to the regions in 
which the operation should be performed. Thus, laryngotomy 
and laryngo-tracheotomy have been extolled as measures- 
adapted for the relief of suffocative angina, whether catar- 
rhal, croupous or diphtheritic. Anyone versed in anatomy 
knows that laryngotomy and laryngo-tracheotomy can be; 
readily performed in the adult. The experienced surgeon 
shrinks from their execution under any circumstances owing 
to the dangers that attend and follow them. Any interfer- 
ence with the structures of the larynx may develop distress- 
ing spasm of the glottis, or initiate fatal inflammation : in 
patients fortunate enough to escape the immediate dangers 
of these procedures, necrosis of the laryngeal cartilages 
frequently ensues, while permanent impairment of the voice 
is an almost inevitable consequence in those who recover. 
The readiness, with which laryngotomy and laryngo-tracheot- 
omy can be performed upon the adult has originated an idea 



3 52 TRACHEOTOMY. 

that these measures can be effected with equal facility upon 
the child. That the}- can be performed, even upon an infant, 
no one denies — that they can be easily executed in a child, 
no one who has attempted either procedure, even upon the 
cadaver, will maintain. The small size and rigid walls of the 
,air-passage at the points where it must be opened, as well as 
the difficulties attendant upon the performance of these 
operations and the dangers associated with them, should 
prevent laryngotomy, or laiyngo-tracheotomy being resorted 
to for the relief of suffocative angina. 

Tracheotom}' is the operation that, as a rule, should be 
resorted to in such cases. But even this procedure has not 
escaped misrepresentation. Some years since a distinguished 
physician, the Professor of Practice in the Universit}- of 
Louisville, spoke of traeheotom}- as the most simple thing in 
the world, which anyone might perform easily with a razor ! 
"Well might Dr. S. D. Gross say, that, had this gentleman 
■ever opened the trachea he would never have made such an 
-erroneous statement ; and add — "the amputation of a limb, 
the extirpation of a glandular tumor, lithotom}' and even the 
perineal section are trifling matters in comparison with 
tracheotomy in a short, thick-necked and restive child." To 
;such statements as the one reprobated hy Dr. Gross, the 
sacrifice of man}' lives and the humiliation of many operators 
lire due. The erroneous impression that tracheotomy 7 is not 
■difficult, that little anatomical knowledge, and no surgical 
experience is demanded for its performance, has led many an 
inexperienced practitioner to attempt the opening of the 
-wind-pipe — attempts that but too frequently have cut short 
the patient's life and injured the reputation of the ph} T sician. 

Various complicated appliances have at different times 
ibeen recommended as mechanical devices that would rid this 
■operation of danger and render its execution eas}\ It is need- 
less to spend time in their enumeration, for, to the inex- 
perienced operator they would be a snare : to the experienced 



TRACHEOTOMY. 153 

surgeon they would be useless. A knowledge ot anatomy 
and a reasonable degree of surgical skill are all that are 
demanded for tracheotomy : the experienced surgeon can 
open the trachea successfully with no other implements than 
.a sharp knife, and such other aids as can be improvised at a 
moment's notice in anj T house. Retractors, tenacula, artery 
forceps, scalpel, sharp and blunt-pointed bistouries, and 
tracheotom}^ tubes, comprise an outfit that supplies the 
surgeon with all the instruments he will be likely to need in 
the vast majority of cases. 

The use of anaesthetics in the operation is a question to be 
decided by no hard and fast rule, but a problem to be solved 
independently for each individual case. The duration of the 
disease, the condition of the respiration and circulation, the 
general state of the patient, and the wishes of the individual 
to be operated upon, are all elements to be taken into con- 
sideration in arriving at a decision. It can be stated 
emphatically, however, that the pain of the operation is 
slight, and that by employing local anaesthesia, or simply 
benumbing the skin over the trachea with ice, even this 
-suffering can be materially reduced. The objections to ether 
•or chloroform in suffocative angina are very great. 

In order to open the wind-pipe satisfactorily, the light 
must be good, and the patient properly placed with reference 
to it, in the supine posture, and should have his shoulders 
supported by one pillow, his head by another, and his neck 
made prominent by a hard roll of cloth between the two. In 
adults it is occasionally desirable to operate with the patient 
in a sitting position — the patient should then support his 
head on the back of the chair. The assistant who is sub- 
sequently to have charge of the sponges now uses the ether 
spray, or ice, and benumbs the integument over the point 
where the trachea is to be opened. This done, the surgeon, 
who stands behind the patient, if sitting, or at his right side, 
if in the recumbent position, steadies th'e integument with 



154 TRACHEOTOMY. 

the fingers of the left hand, and makes an incision through 
the skin an inch and a half, or two inches long, the center of 
the cut resting over the third tracheal ring. This incision is 
carried down until the fibrous bands uniting the muscles on 
either side of the mesial line are exposed. Any blood-vessels 
exposed in the procedure are either drawn to one side, or 
ligated at two points and cut between. A few strokes of the* 
knife loosen the central attachments of the muscles, and 
permit them to be drawn aside. The handle of the scalpel 
may now clear the anterior surface of the trachea of all over- 
ling structures save the layer of firm fascia in immediate- 
contact with it. If the thymus gland projects upward, it 
can be drawn down ; if the thyroid isthmus projects down- 
ward, it can be drawn up ; vessels can be pulled to one- 
side — in a word any structure the surgeon does not wish to 
cut can be loosened and removed out of the way. The fascia 
covering the trachea should now be incised, the latter is thus- 
exposed, and if the subsequent incisions have all been made 
the length of the original opening in the skin, and the 
hemorrhage has ceased, the surgeon is ready to open the 
wind-pipe. In order to do this, the trachea is steadied with 
a tenaculum, and one ring cut through with a sharp-pointed 
curved bistoury ; a blunt-pointed bistoury is passed through 
the opening, and the incision enlarged to a degree sufficient 
to admit the tracheotomy tube — if no tube be at hand an 
elliptical piece is cut from the anterior portion of the trachea, 
and pains taken to keep the edges of the wound widely 
separated by some kind of improvised retractors as wire 
bent to suitable shape. If a tube is to be inserted, so soon as- 
the opening in the trachea has been enlarged to a sufficient, 
extent, the surgeon passes his finger into the trachea, and at 
once follows it with the tracheotomy tube, the finger serving- 
as a guide to pilot the tube into the air-passage. Should the 
patient be able to breathe through the tube, all that remains 
to be done in ordinary cases is to fasten the flanges of the 



TRACHEOTOMY. 155 

outer tube around the neck by means of tapes, and give 
directions for the after treatment. 

The incision into the trachea should be of such a size as- 
to fit snugly the tube when the latter is in place. Inasmuch 
as the opening in the skin is much longer than that in the 
wind-pipe, it may be necessary to draw the edges of the 
latter together with sutures after the tube is introduced. 
Yet I have not always found this good practice : on the 
contrary, if the parts between the trachea and flange of the 
canula be filled with absorbent cotton, it will serve a three- 
fold purpose — hemorrhage will be guarded against ; the 
wound will be protected from the irritating influence of the 
tracheal discharge ; and the opening into the wind-pipe will 
be the sooner consolidated to such an extent as to permit the 
removal of the tracheotomy tube. It generally takes three 
days for the wound to assume such a state that it remains 
patent when the tube is withdrawn. During this time the 
outer tube should not be disturbed ; if accidentally displaced,, 
the surgeon himself should return it. The inner tube can 
be removed for cleansing at any time it may seem necessary, 
and this duty can be performed by the nurse. When the 
trachea is opened the patient generally struggles for air — 
the insertion of the tube and change of the patient's position 
afford relief. In a short time tracheal mucus of an adhesive 
stringy character begins to be voided. After a while it may 
accumulate to such a degree that even frequent removals of 
the inner tube no longer suffice to keep the passage-way 
clear : in these cases, in addition to washing the inner tube 
in hot water every fifteen minutes or so, the nurse will have 
to use feathers to extract the mucus that accumulates below 
the canula. In all cases where tracheotomy has been per- 
formed, surgical aid should be close at hand for the first two- 
d&ys after the operation. Immediately after the tube is- 
introduced and it is seen that the patient breathes well, 
blankets may be hung about the bed in such manner as to» 



156 PLASTIC BRONCHITIS. 

isolate the patient and permit his being subjected to the 
action of steam without filling the whole room with aqueous 
vapor. The tube may have to be taken away before the 
wound has had time to consolidate ; under such circum- 
stances retractors must be used to keep the edges asunder 
until the opening is rendered patent by plastic material. 
For the first few da}~s the patient's diet should consist of 
fluids : there is no objection, however, to the administration 
of such drugs as the physician may deem necessary for the 
proper medicinal treatment of the case. 



CHAPTER XXIV. 
PLASTIC BRONCHITIS. 

Plastic Bronchitis, denominated also fibrinous bronchitis, 
croupous bronchitis, &c, is a distinct disease which is believed 
to have its seat primarily in the bronchi of the third and 
fourth order. Its remarkable and diagnostic feature is the 
formation, or, rather, exudation, upon the interior of the air 
passages, below the trachea, of a membrane in character 
identical with that described in pseudo - membranous laryn- 
gitis as located upon the walls of the larynx ; and in diph- 
theria, in the pharj-nx and elsewhere. These diseases, although 
very diverse in their other characteristics, exhibit by this sim- 
ilarity, a relationship which is at least ver} T suggestive in re- 
gard to their classification and therapeutic management. On 
account of the identity of the membranes, Sir John Rose Cor- 
mack " suggested that plastic bronchitis may be a variety of 
diphtheria "; and numerous writers of great distinction, Mack- 
enzie with others, for the same reason, teach that croup is truly 
and only laryngeal diphtheria ; while Niemeyer has called it 
bronchial croup. Such doctrines indicate the recognized rela- 
tionship, based on the plastic phenomenon, common to each of 



PLASTIC BRONCHITIS. 157 

these diseases ; which, however, is quite insufficient, as shown 
in the previous pages of this work, to establish their identity; 
their distinctive features are too numerous, uniform, and em- 
phatic to be reconcilable with such an idea. In systems of 
nosology, however, classes are formed upon analogies less 
apparent, and no good reason exists why these three distinct 
diseases, thus related, should not be grouped as a separate 
class, to be denominated Membranous diseases. 

The class thus formed, though small, is second to none in 
importance, and this last of the series, although much less 
common, is hardly less grave than its predecessors. 

It is observed both as an acute and chronic affection ; most 
frequently in young adults, although no period of life is 
known to be entirely exempt. 

Niemeyer mentions the case of a girl fifteen years old who 
had almost daily, for years, coughed up almost a complete 
cast of the left bronchial tree. 

Causes. Of the causes of plastic bronchitis we know as 
little or less than is known of those of laryngeal croup. The 
type of the inflammation is thought to be similar in the two 
as their products are identical, and also from the tendency of 
both to extend downward from their original sites, and the 
general absence of symptoms, except such as depend upon 
the local disease. 

The more rapid progress of croup is thought to depend upon 
its location at the fountain head of the respiratory current, 
and upon the exquisite sensibility of the larynx, which can- 
not be made tolerant of the foreign body (the membrane) as 
are the lower air passages. 

Inhalation of cold air, and bodily exposure we know 
aggravate the sjmiptoms of this disease, but their influence 
in its causation can only be inferred. It is proper here to 
remark that the disease is neither contagious nor epidemic ; 
and so rare as to afford little opportunity to investigate its 
nature or causes. 



158 PLASTIC BRONCHITIS. 

An idiosyncraey, or peculiar state of the blood, as causative 
agencies are suggested by the membranous deposits and its 
analogies to croup noted above. 

Anatomical appearances. " In primaiy independent croup- 
ous bronchitis (i. e. plastic bronchitis) the same condition of 
the bronchial mucous membrane is found, and with the same 
coagulated exudation upon it, which we have described as 
existing upon the mucous membrane of the larynx in laryngeal 
croup. In the larger bronchi the caliber of the canal is not 
usually completely occluded ; and the coagula are tubu- 
lar ; but in the smaller bronchi they form cylindrical plugs. 
Croupous bronchitis is seldom spread over the whole lung ; 
generally it is partial, and confined to a small number of 
bronchi ; but to this rule there are exceptions." (Nieme} T er.) 

The larynx and trachea, it is believed, are never involved 
as in croup and diphtheria. 

Symptoms and diagnosis. — These, as before stated, depend 
largely upon the local disease ; the constitutional perturbation 
whatever it may be, is not declared by known phenomena 
except the exudation, the existence of which is only determin- 
able by portions expectorated. If suspicious coagula appear 
in the sputa, they should be carefully rinsed in water and 
soaked in dilute acetic acid ; if only condensed mucus they 
will shrink and be rendered firmer, and the case is ordinarj r 
bronchitis ; if fibroid, they will swell and soften and indicate 
the plastic type. 

S} T mptoms of acute inflammation, fever and pain, are gen- 
erally slight or entirely absent. When, however, these exist 
continuously, with extreme dyspnoea, they indicate an exten- 
sive, acute, and very dangerous form of the disease that may 
terminate in fatal asphyxia. 

More or less febrile action, however, is excited, even in 
chronic cases, by the violent and prolonged cough and labored 
breathing attendant upon the separation of masses of the 
exudation ; which, with the cough, quickly subsides when the 



PLASTIC BRONCHITIS. 159 

mass is expectorated. Blood}* sputa, more or less abundant, 
often precedes and generally follows, for a few days, these 
occasions ; during which the cough and dyspnoea increase to 
fearful violence, and the patient appears in the greatest danger 
of suffocation. 

When the affection is acute, the casts are quickly renewed, 
and the course of the disease is limited to a few weeks at most, 
and is said to prove fatal in about fifty per cent, of the entire 
number of cases. 

In the chronic form the casts are also often reproduced and 
the affection may continue for years with but little clanger to 
life. 

The membranous casts when expectorated, may be in convo- 
luted masses or in the form of branching tubes with clean cut 
edges, or as solid branching rods if formed in the bronchi of 
finer caliber. When expectorated in masses, if placed in 
water and unfolded, they exhibit most interesting models of 
portions of the bronchial tree ; the trunk being sometimes 
from a tube of the third or fourth degree, with branches 
diminishing in size with the successive divisions, to mere 
capillaries. 

The patients generally suffer from dyspnoea in proportion 
to the extent of the obstruction. The respirations are quick- 
ened from the same cause and in the same ratio. Cyanosis 
is apparent at times, due to the imperfect aeration. 

The cough, except about the periods of expulsion of mem- 
branes, is dry and harassing. 

Auscultation and percussion furnish almost no aid in the 
diagnoses of fibroid bronchitis and are of as little service in 
its treatment. So long as the bronchial obstruction is com- 
plete the respirator}* murmur is destroyed over the pulmonary 
area deprived of respiration ; and enfeebled if the obstruction 
be only partial. 

Partial bronchial obstruction, according to its degree, also 
occasions correspondingly varying sibilant sounds. A coarse 



160 PLASTIC BRONCHITIS. 

flapping rale is observed sometimes, and attributed to partially 
detached membranes fluttered by the respiratory currents. 

The resonance on percussion and the vocal fremitus are 
not noticeably changed, except from collapse of the lung sub- 
stance ; or from solidification from localized pneumonia, which 
sometimes happens, and in either case more or less dullness 
is occasioned. In diagnosis none of these sounds are at all 
distinctive until after their significance has been shown by 
the expectoration of fibrinous clots or casts. 

The respiratory movements of the chest are perceptibly 
diminished if the obstruction cuts off a due supply of air from 
any considerable portion of the lungs. This is only percept- 
ible upon one side, when the disease, as is common, is limited 
to one lung. 

The most frequent complications of plastic bronchitis are 
phthisis and pneumonia, which reveal themselves by the 
superaddition of their appropriate well known symptoms. 

Treatment. The recognized analogy of fibrinous bronchitis 
to croup, has led, as might be expected, to a corresponding 
similarity of medical treatment. " The treatment is to be 
conducted upon the principles laid down for the management 
of laryngeal croup." (Niemeyer.) To effect the speedy sepa- 
ration and expectoration of the casts, the inhalation of warm 
steam is regarded as of undoubted utilit3 T , as are also vapors 
or sprays containing chloral lrydrate (JJ. 9, 10, 11), lactic acid 
(3 .16), or lime (1^ .18). The vapor of lime and chloral (1^ .17), 
is recommended. 

Emetics are also used when the obstruction has become con- 
siderable, to promote the dislodgment and expulsion of the 
casts. Those advised for croup are especially appropriate. 
(See croup.) 

"Kugel and other German authors recommend especially 
the muriate of apomorphia as an especially appropriate emetic 
in consequence of the promptness of its operation with but 
little nausea, and the absence of unpleasant after effects." 



PLASTIC BRONCHITIS. 161 

(Flint, see also Ziemsen's Cyclopedia, vol. 4, p. 467.) In this- 
country it is rarely employed, and, on account of the danger- 
ous depression sometimes following its exhibition and the- 
difficulty of preserving it, it is not to be recommended. The 
mechanical emetics, t. e. the sulphates of copper and zinc, yellow 
sulphate of mercury, alum and mustard are equally prompt 
and more safe, and therefore preferable. 

" Aside from the treatment having immediate reference to* 
the removal of the casts, measures for the relief of the bron- 
chitis are indicated. For this object the iodide of potassium 
has been found especially useful." (Flint.) " I have never 
observed any benefit resulting from its action in this disorder." 
(Niemeyer.) " This remedy is said to have been employed 
with success." (Prof. A. T. H. Waters, Liverpool.) 

I have used iodide of potash faithfully in a chronic case of 
this anomalous affection, without being able to discover any 
beneficial effect. The same case, when later put upon arsenic,, 
iron and cod-liver oil, convalesced and complete recovery 
resulted, though not speedily. 

Admitting the importance of those measures of treatment 
to effect the separation and expulsion of the casts, and all 
such also as are employed " for the relief of the bronchitis," 
and these embrace all measures of acknowledged efficacy in 
other forms of bronchitis, it is observed that writers on thi& 
affection are quite as conspicuous by the omission of all ref- 
erence to a possible primary constitutional implication, as b} r 
the constant suggestion, if not positive affirmation that the 
disease is of local origin ; a partial or limited, specific form 
of bronchial inflammation. 

The question, Is the disease a specific form of inflammation,, 
or, the result of constitutional causes ? although apparently 
overlooked, cannot be ignored by the thoughtful clinician. 
This much can be positively affirmed : — the ordinary causes- 
of bronchial inflammation do not induce fibroid exudation - r 
else this phenomenon would be as common as other types of 
11 



162 PLASTIC BRONCHITIS. 

bronchitis. If the affection be then a specific form of local 
bronchitis, not from ordinary causes, } T et as it probably does 
not exist without cause, that cause must be special ; and from 
its infrequency, is most likely personal and S3~stemic. Such 
•exceptional manifestations are no doubt connected with, or 
caused bj T , a constitutional vice, or, what amounts to the same 
thing, a disordered state of the blood. This view is further 
confirmed by the almost uniformly pale and cachectic appear- 
ance of the patients (at times cyanotic from imperfect breath- 
ing); and, its acceptance by writers may also be argued from 
the use of such constitutional remedies as iodide of potash, 
arsenic, iron and cod-liver oil. 

None of the remedies emplo} T ed for the cure of this disease 
are known to possess aplastic properties, or efficacy in antago 
nizing in the blood, the tendency to part with its fibrine, so 
clearly exhibited in this and the other membranous diseases. 
Certainly one of the clear indications of treatment, is to cor- 
rect the constitutional affection by such remedies as "are 
known to possess the power to limit or prevent an exuda- 
tion." 

At the head of this class of remedies we place chloral hyd- 
rate, either alone or conjoined with bromide of ammonium or 
chlorate of potassium, substantially as shown in 1^ . 22, 23. 
These remedies are advised, in plastic bronchitis, mostly on 
theoretical grounds ; no sufficient opportunities having occur- 
red to the writer, since the introduction of the chloral treat- 
ment, to fulty test their efficacy in typical cases of this disease, 
as has been done in diphtheria and croup. In chronic forms 
of disease, there is manifestly no occasion to push these rem- 
edies as advised in acute forms, in which the progress is rapid 
and the perils immediate. 

Ample nutrition is a part of the treatment of every case 
of plastic bronchitis, not to be overlooked, nor considered of 
secondary importance. 



FORMULAE. 



The formulae here given may be variously altered to adapt 
them to various ages, degrees of violence, and stages of disease, 
and to the tastes, susceptibilities and tolerance of patients, and the 
judgment of the practitioner. It is believed, however, that in 
the main they will, as written, meet the indications for their use. 

They are not all original, but have been gleaned from various 
authentic sources, and are not presumed to represent all the 
remedies needed in the treatment of the membranous diseases. 



Local Remedies. 
l. 

3, . Pot.Permanganat. gr. x a xx. 
Aquae § i. M. 

Useful in gangrene, &c. 
Apply to fauces with large 
camel's hair brush. 

For atomizer reduce ^. 

2. 

1^, . Chloral Hyd. 3 ss a 3 iss. 
Sir. Cort. Aurant. | ss. . 
Aquae J i. M. 



Or, 



3. 



fy . Sol.Chlor. Hyd.(gr. 40 to ? i) 5 ss. 
Tr. Iodin. C. 3 iii. 

Glycerin. 5 ss. 

Aq. Menth. Pip. ad \ ij. 

M.' 



For use as No. 1 in fauces, 
for effect upon false membrane 
and disinfection. 



4. 

# . Chlor. Hyd. 
Tr. Iodin. C. 
Glycerin. 
Aquae 

Or, 

5. 



31- 



aa I ss. M. 



3i. 



aa 



ss. M. 



3 . Chloral Hyd. 
Tr. Iodin. C. 
Glycerin. 
Tr. Gaulth. 
Aquae 

For external use in glandular 
and other swellings. — Apply 4 
times a day, and keep the parts 
well covered with dry, soft 
flannel. 



163 



164 



FORMULAE. 



6. 

^ . Chloral Hyd. 
Spt. Gaulth. 



gr. x a xxx. 

3i. M. 



Or, 



7. 



}£ . Chloral Hyd. gr. x a xxx. 
Sol. Sod. Borac.(gr. xa 3 i) 
Aq. Menth. Pip. aa J ij. 

M. 
For injecting into nasal pas- 
sages to cleanse and disinfect. 

Or, 

8. 

^,. Acid.Carbol. 
Glycerin. 
Aquae 



gtt. xxiv. 

Svi. M. 



For Atomizing. 



1^ . Pot. Permang. gr. v. 
Aquae § i. M. 

To be used in atomizer for 
disinfecting. Instead of the Pot. 
Permang. in 9, use, if preferred, 
5 grains each of Chloral Hyd. 
and Pot. Chlor. 



10. 

# . Chlor. Hyd. 
Spt. Gaulth. 
Aq. Pur. 
Aq. Calc. 

Or, 

^ . Chlor, Hyd. 
Acid. Carbol. 
Aq. Calc. 
Aq. Gaulth. 



gr.x. 
3*. 

aa § iss. M. 



gr. x. 
gr. xv. 



aa 5 iii. M 



Or, 



11. 



5, . Amnion. Brom. 

Potas. Brom. cagr.vax, 
Aquae 3 iss. M. 

The last three useful in laryn- 
geal diphtheria and croup, every 
1, 2, 3 or 4 hours for 15 min- 
utes. 

12. 

1£ . Acid. Salicyl. 

Sod. Borac. 00 gr. v. 

Aquae ? i. M. 



Or, 



13. 



^,. Acid. Salicyl. 
Glycerin. 
Aq. Calc. 

Or, 

14. 

"fy . Acid. Carbol. 
Glycerin. 
Aquae 

Or, 

15. 

I^.Acid. Carbol. 
Pot. Chlorat. 
Glycerin. 
Aquae 

Or, 

16. 



3ss. 
I iii. M. 



gtt. xxii. 
\ vi. M. 



gtt. xxii. 
3 iii. 

1 iii. 
J v. 7rf. 



gr. xx. 
?i. itf. 



I£ . Acid. Lactic. 
Aquae 

Recommended also in laryn 
geal diphtheria and croup. 



FORMULAE. 



165 



The following are appropriate 
quantities of the medicines named 
for each ounce of water for spray 
inhalations. 

Many other medicines and 
various combinations are also 
employed in this manner, as the 
judgment of the practitioner or 
accredited authorities may in- 
dicate. 

If a hand ball atomizer, which, 
when well constructed, answers 
every purpose, is emp^ed, let 
the fluid be warmed to 100° F. 
or upwards. 

Acid. Tannic. gr. iii a v 

*' Lactic. gr. xx. 

*' Carbol. gr. iii. 

Ammonium Brom. gr. v a x. 
Aq. Calc. (undiluted) 

Chloral Hyd. gr. v. 

Fer. Perchlor. gr. iii. 

" Sulph. gr. iii. 

Potas. Permanganas. gr. v. 

" Chloras. gr. xx. 

" Bromidum gr. xv. 

Vapor Inhalations. 

17. 

fy . Fresh Lime lb i- 

Water containing Chlo- 
ral Hyd. 3 i 0. i. 

Or, 

18. 

J$, . Fresh Lime ft i. 

Water 0. i. 

Put the lime in lumps into a 
coffee-pot, open mouthed bottle 
or fruit jar, pour upon it the 
fluid (to the spout of the coffee- 
pot or similarly constructed ves- 



sel may be attached a piece of 
rubber tubing of convenient 
length when desired), and when 
the vapor begins to rise direct 
it into the patient's face so it 
must be freely inspired ; use 
every hour in laryngeal" cases 
and croup. Of inestimable value. 

General Remedies, 



19. 

r> , Pot. Chlorat. 
Amnion. Mur. 
Glycerin. 
Aquae 



3 ij- 

I vi. M. 



(riven in cases of croup, &c, 
in one or two drachm doses 
every hour, according to age. 

20. 

J£ . Quin. Sulphat. 3 ss. 

Elix. Tarax. C. 3 ij. M. 
Dose, teaspoonful every two 
hours for a child of 5 years, 
and alternated with 

21. 

1} . Tr. Fer. Chlor. 3 ij. 

Pot. Chlorat. 3 ij. 

Sir. Simp. | iv. M, 

Dose, same as 20. 

Prof. Smith declares this in 
his hands "the most satisfactory 
treatment " in diphtheria. 

22. 

^ . Chloral Hyd. 

Pot. Chlorat. aa gr. xcvi. 

Spt. G-aulth. vel. 

Spt. Menth. Pip. 3 i. 

Aquae 

Sir. Simp. aa^\]. M, 



1G6 



FORMULAE. 



Of great value in diphtheria. 
Dose for an adult two teaspoon- 
fuls every hour when awake. 

No drink to follow the ad- 
ministration for 8 or 10 minutes. 
The degree of somnolence is 
somewhat a measure of the effect 
of chloral, and should influence 
accordingly. 

The pungency of this and 
the followino; Chloral mixtures 
should, by varying their strength, 
be adapted to the different fau- 
cial sensibility of patients, which 
can be judged by the complaint, 
if any, of pain following the 
administration. 

23. 

^ . Chloral Hyd. 

Pot. Chlorat. aa gr. xlviii. 

Spt. Gaulth. vel. 

Spt. Menth. Pip. 3 i. 

Sir. Simp. 

Aquae aa 3 ij. M. 

Give a teaspoonful or tea- 
spoonful and a half every hour 
when awake to a child from 5 to 
10 years of age. 

See also remarks under ]$, . 22. 

24. 

5. Chloral Hyd. 

Ammon. Brom. aagr. lxxx. 

Spts. Chloroform. 3 i a ij. 

Sir. Simp. 

Aquae aa 3 ij. M. 

Give to adults two teaspoon- 

fuls every hour, and to children 

above 10 yrs. one, in laryngeal 

diphtheria and croup. 



For younger children use the 
following : 

25. 

fy . Chloral Hyd. 

Ammon. Brom. aa gr. 1. 

Spts. Chloroform. 3 i a ij. 

Sir. Simp. 

Aquae aa 3 ij . M. 

Give a teaspoonful every hour 
when awake. 

These are cases of the gravest 
danger, and demand the utmost 
vigilance in the use of both local 
and general treatment. 



26. 

Ijt * Sod. Sulphocarb. 
Simp. 



eir. 



Aquae 



3y. 
aa \ i. M. 



For a child of five years, tea- 
spoonful every 3 hours. 



g r - 



■i? a 



r. 1 a i J. 



27. 

]^ . Pilocarpin. 
Pepsin. 

Acid. Hydrochlor. gtt. ij 
Aquae § ijss. 

M. 
Give a teaspoonful hourly to 
children. 

28. k 



fy . Pilocarpin* 
Pepsin. 

Acid. Hydrochlor. 
Aquae 



gr. iss. 

gr. xxx. 

gtt. viii. 

I ijss. 

M. 

Give a teaspoonful hourly to 
adults. 



INDEX. 



Abscesses of lymphatic glands in diphtheria, 59. 
Aitkin, 85. 

Alcohol, use of, in diphtheria, 80, 109, 121. 
Albuminuria in diphtheria, 7, 32, 34, 35. 
Aluminum, sulphate of, in croup, 140. 
Ammonium bromide in croup, 145. 
chloride in croup, 144. 
Antimonials in diphtheritic laryngitis, 140. 
Antiquity of diphtheria, 9. 
Antiseptics in diphtheria, 53.- 
Atmosphere, influence of, 37. 
Atomizer, use of, in laryngeal diphtheria, 124. 

Bacteria, 21, 72. 

germs, 27. 

in diphtheria, 29. 

in non-diphtheritic states, 29, 30, 72. 
Bacterian theory untenable, 25, 26, 37. 
Ballard, 41. 

Balsam of Copaiba in diphtheria, 107. 
Bard, 14. 

Baths in diphtheria, 81. 
Blood, the, in diphtheria, 75, 76. 
Blood-poisoning in diphtheria, 30, 32, 35, 58, 60. 
symptoms of, 68. 
secondary, 58. 
Brain, the, in diphtheria, <5. 
Bretonneau, 18, 39. 
Bristowe, 84. 

Bromides in diphtheria, 106. 
Bromine in diphtheria, 106. 
Bronchitis, plastic, or fibrinous, 129. 

(167) 



168 INDEX. 

Catarrh a predisposing cause of diphtheria, 42, 55. 
Cathartics, use of, in croup, 141. 

in diphtheria, 94. 
Causes of death in croup, 138. 

in diphtheria, 68. 
Causes of croup, 129. 

of diphtheria, 20. 

predisposing, of diphtheria, 39. 
Caustics, use of, 87, 88. 
Chapman, 109. 
Chloral in croup, 145 et seq. 

in diphtheria, 87 et seq., Ill et seq. 

exists in the blood as chloral, 115. 

not depressant, 117. 

prevents coagulation of the blood, 113. 

used in all cases, 119. 
Chlorate of potassium in the treatment of croup, 144. 

of diphtheria, 104 et seq. 
Olimatic and atmospheric influences, 37. 
Coagulation of the blood prevented by chloral, 113. 
•Constitutional nature of diphtheria, 7, 30. 

treatment of diphtheria, 92. 
Contagium of diphtheria, 26. 
Convalescence, 59. 
Copaiba in diphtheria, 107. 
Copper, sulphate of, in croup, 140. 
Creasote, use of, 85. 
■Croup, 129. 

and diphtheria, symptoms compared, 123. 

and laryngeal diphtheria, identity or non-identity of, 129. 

aetiology of, 129. 

aphonia in, 136. 

asphyxia in, 136. 

causes of death in, 138. 

cough in, 131, 136. 

examination of sputa in, 133. 

exudate in, 134, 138, 139. 

membrane in, 130. 

nature of, 131. 

nomenclature of, 130. 



INDEX. 169 

Croup, pathology of, 138. 

respiratory sounds in, 131. 

symptoms and diagnosis, 131 et seq. 

treatment of, 139. 

use of chloral in, 145 et seq. 

use of laryngoscope in, 133. 

voice in, 136, 137. 
Croupous diphtheria, 51. 
Cubebs in diphtheria, 107. 

Deglutition, difficulty of, caused by paralysis, 62. 
Diagnosis between diphtheria and membranous laryngitis, 65. 

and quinsy, 66. 
and scarlatina, 65. 
and thrush, 65. 
Diagnosis of diphtheria, 64. 
Diphtheria a constitutional disease, 7, 30. 

age when it occurs, 39. 

albuminuria in, 49. 

causes, 20. 

predisposing, 39. 

constitutional nature of, 7, 30. 

predisposition to, 40. 
treatment of, 92. 

definition of, 7. 

diagnosis of, 64. 

feeding in, 78. 

gangrene in, 54, 70. 

hemorrhages in, 54. 

history of, 8. 

incubation of, 42. 

laryngeal, 51. 

malignant, 46. 

mortality in, 67, 115. 

nasal, 52, 121. 

of Eustachian tubes, 52. 

of lachrymal duct, 52. 

of rectum, 53. 

of vagina, 53. 

of wounds, 7, 53. 



170 INDEX. 

Diphtheria, predisposing causes of, 39 et seq. 
prognosis in, 69. 

prophylaxis and prophylactics in, 44. 
sequelae of, 60, 63. 
sewers and, 41. 
sex in, 40. 

skin eruption in, 55. 
symptoms of, 45 et seq. 
synonj^ms of, 8, 11. 
temperature in, 56. 
treatment of, 77 et seq. 
unfavorable symptoms in, 69. 
uraemia in, 68. 
Diphtheritic croup, 51. 

exudate, 50. 

laryngitis and membranous croup, 15, 66, 1231 

membrane, 50, 70. 

mode of production of, 71. 
membranes, separation of, 57. 
paralysis, 60, 126. 

causes of, 63. 

electrical applications in, 127. 
frequency of, 63. 
statistics of, 61. 
treatment of, 126. 
Duration of incubation of diphtheria, 42. 

Eberth, 24, 72. 
Emetics in croup, 140. 

in diphtheria, 95. 
Epistaxis in diphtheria, 123. 
Eustachian tubes, diphtheria of, 52. 

Feeding in diphtheria, 78. 

Fibrinous or plastic bronchitis, 129, 130, 156. 

exudations, 130. 
Fomentations, use of, 91. 
Formulae, 163. 

Gangrene in diphtheria, 54. 



INDEX. 171 



General treatment of diphtheria, 77. 
Glands, swelling of the, in diphtheria, 36, 74 
Guttmann, Dr., 108. 

Heart affections in diphtheria, 74. 

Hemorrhage in diphtheria, 54. 

History of diphtheria, 8. 

Hydrargyrum in the treatment of diphtheria, 106. 

Hydrochloric acid, use of, 85. 

Ice in diphtheria, 90, 91. 

Incubation of diphtheria, duration of, 42. 

Infection of diphtheria, manner of, 40. 41. 

Inhalations of steam in croup, 147. 

Inoculability of diphtheria, 40. 

Ipecac in diphtheritic laryngitis, 140. 

Iron in the treatment of diphtheria, 96 et seq., 116. 

Kidneys, symptoms connected with, 32, 76. 

Labadie Lagrave, 56. 
Lachrymal duct, diphtheria of, 52. 
Lactic acid, use of, in diphtheria, 125, 
Laryngeal diphtheria, 123. 

treatment of, 124. 
Laryngoscopic examination in croup, 133. 
Laryngotomy, 151. 
Laryngo-tracheotomy, 151. 
Lime water in diphtheria, 86, 122, 125. 
Local treatment in diphtheria, 84. 
Lung affections in diphtheria, 74. 

Mackenzie, 32, 36, 37. 

Measles and scarlatina predisposing causes, 42. 

Medical prophylaxis, 127. 

Membrane, diphtheritic, 35. 

in croup, 134, 138, 139. 

seat of, in diphtheria, 35. 



172 INDEX. 

Membrane, decay of, 53. 
Membranous croup, 129. 

diagnosis of, I31~et seq. 

treatment of, 139. 
Membranous deposits in larynx, 134, 138, 139. 
Mercury in treatment of croup, 141 et seq. 

of diphtheria, 106. 
Micrococci, 22 et seq., 29. 
Microzymes, 28. 

Mode of propagation in diphtheria, 39. 
Moist air in croup, 147= 
Mortality in diphtheria, 67, 77. 
Muguet and diphtheria, 65. 

Nasal diphtheria, 52, 121 

epistaxis in, 123. 

treatment of, 122. 
Nitrate of silver in the treatment of diphtheria, 86. 
Nomenclature, 2. 
Nourishment in diphtheria, 78. 

Oertel, 23, 86. 

Paralysis diphtheritic, 126. 

affecting vision, 61. 
frequency of, 63. 

of extremities, 62. 

of heart, 62. 

of muscles of neck, 62. 

of muscles of trunk, 62. 

of pharynx, 61. 

of sphincters. 62. 
Pilocarpin, use of. in diphtheria, 107. 
Potassium chlorate, in diphtheria, 104 et seq. 

sulphide, use of, 106. 
Plastic bronchitis, 156. 
Poultices, use of, 80, 91. 
Prognosis in diphtheria, 6Q. 
Prophylaxis, medical, 127. 



INDEX. 173 



Propagation, mode of, in diphtheria, 39. 
Pyasmia, 53. 

Quinia in croup, 145. 

in diphtheria, 96, 100. 

Rectum, diphtheria of, 53. 
Rokitansky, 89. 

Salicylic acid in diphtheria, 106. 

Secondary blood-poisoning, 58. 

Senega in diphtheria, 108. 

Septicaemia, 73. 

Sex in diphtheria, 40. 

Silver nitrate in diphtheria, 86. 

Sinapisms, 80. 

Skin eruption in diphtheria, 55. 

Spray inhalations in croup, 147. 

Sputa, examination of, in croup, 133. 

Sulphide of potassium, 106. 

Sulphites, use of, 106. 

Sulphur, 87. 

Symptoms of diphtheria, 36. 

unfavorable, in diphtheria, 68. 
Synonyms of diphtheria, 8, 11. 

Thrombi in diphtheria, 68, 75. 
Tonsils, ulceration of, 59. 
Tracheotomy, 148, 150. 

anaesthetics in, 153. 
in diphtheritic laryngitis, 125. 
mode of operation, 153. 
statistics of, 149. 
Treatment of diphtheria by chloral, 111 et seg. 

constitutional, 92. 
general, 77. 
local, 84. 
therapeutic, 81. 
Trousseau, 41, 60, 105. 
Tympanum, perforation of, 52. 



174 INDEX. 

Ulcers of tonsils and fauces, 59. 
Urea increased in diphtheria, 33. 
Urine, casts in, 23. 

albuminous, 32. 

Vaginal diphtheria, 53. 
Vance, 151. 

"Wounds, diphtheria of, 7, 53. 



